Long-Term Clinical and Angiographic Follow-up in Patients With Isolated Ostial Stenosis of the Left Coronary Artery

Abstract

solated ostial stenosis (IOS) of the left coronary artery (LCA), in the absence of distal vessel obstruction, is a rare form of coronary artery disease. It is neither associated with Takayasu arteritis, syphilitic aortitis, congenital anomaly, aortic valve disease nor iatrogenic cause such as mediastinal irradiation or cardiac surgery. Atherosclerosis, particularly early atheroma, has been considered its most likely cause, but its etiology is quite unknown. In such cases the occurrence has usually been in premenopausal women, 1 and the clinical profile might differ from that of the more common atherosclerotic stenosis of the left main trunk (LMT). 2 The clinical features of patients with IOS have gradually come to light, but the long-term prognosis and serial angiographic follow-up in patients with IOS who undergo coronary artery bypass grafting (CABG) have not been fully studied. Methods Study PopulationWe investigated 57 patients with stenosis of the LMT who underwent CABG. They underwent coronary angiography and subsequently treatment for myocardial ischemia before 1994. All patients underwent CABG at Juntendo University and were followed at Juntendo University Urayasu Hospital. They were categorized into 3 groups based on the angiographic findings: Group I comprised 9 patients with IOS ( Figure 1A); Group II comprised 12 patients with LCA ostial stenosis in the presence of distal vessel obstruction ( Figure 1B); Group III comprised 36 patients with stenosis of the LMT excluding ostial stenosis, and associated with distal vessel obstruction ( Figure 1C). We studied the coronary risk factors and prognosis in all patients. Hypercholesterolemia was defined as a requirement for antihyperlipidemic drugs or a total cholesterol (TC) level >220 mg/dl. Diabetes mellitus (DM) was defined as a requirement for therapy and/or with a fasting blood sugar >140 mg/dl, and/or a blood sugar >200 mg/dl on occasion. Baseline clinical and procedural data were collected for all patients. Coronary AngiographyThe patients underwent serial angiography at 1, 5, and 10 years after CABG, regardless of their symptoms, under informed consent. The films were of good quality and the repeat studies were always compared with the baseline coronary arteriogram. The films were read on 2 adjacent projectors by 2 angiographers working together to reach a consensus. The stenosis of the coronary arteries and grafts were defined as the linear percentage of narrowing of the diameter of the vessel compared with the diameter of the nearest normal segment. The severity of the stenosis was evaluated according to the American Heart Association Committee Report. In this study, graft patency was considered to be widely patent or the presence of stenosis <99% narrowing. In the follow-up angiography we studied the Long-Term Clinical and Angiographic Follow-up in Patients With Isolated Ostial Stenosis of the Left Coronary ArteryMizuhiro Arima, MD; Tatsuji Kanoh, MD*; Shinya Okazaki, MD*; Yoshitaka Iwama, MD*; Shigeru Matsuda, MD**; Yuji Nakazato, MD** Backgroun...

Robotic totally endoscopic coronary artery bypass for isolated ostial stenosis of the left coronary artery

“…Therefore, CABG is a reasonable option for revascularization to prevent from the atherosclerotic plaque disruption, and the platelet aggregation. A long-term clinical review and angiographic follow-up of nine patients, by Arima and colleagues, has proved that CABG with LITA graft is safe and effective in treating IOS of the left coronary artery (3). Besides, saphenous vein patch angioplasty was also reported with acceptable long-term outcomes (4).…”

“…The high incidence in premenopausal young women with few coronary risk factors and the different clinical characteristics cannot be entirely explained. Consequently, unknown inflammatory process possibly involves aortocoronary junction and results in ostial stenosis (2,3). Previous studies have presented high rates of restenosis and in-hospital mortality in both stenting and endarterectomy of ostial lesion (8).…”

Revascularization by percutaneous coronary intervention in a case of left main coronary artery atresia

“…Isolated LM stenosis or occlusion occurs predominantly in young to middle‐aged women. The etiology remains unclear, but candidates include the presence of syphilitic aortitis, Takayasu arteritis, congenital hypoplasia or atresia, iatrogenic causes such as mediastinal irradiation or cardiac surgery 5 . An early identification of the etiology may enable an appropriate therapeutic approach, allowing a better outcome for these patients.…”

Chronic competitive flow from a patent arterial or venous graft to the circumflex system does not impair the long-term patency of internal thoracic artery to left anterior descending grafts in patients with isolated predivisional left main disease: Long-term angiographic results of 2 different revascularization strategies

“…Isolated ostial stenosis of the left main coronary artery is a rare form of coronary artery disease with peculiar etiologic, pathologic, and clinical features. 1 The surgical approach to IOSLM is still matter of debate: the use of a single ITA-LAD graft, of bilateral ITAs, or of a mixed ITA plus SV configuration have all been advocated. 3 In any case, surgical revascularization has been reported to achieve suboptimal results: Arima and colleagues 1 reported a disappointing 62.5% patency rate at 10 years in this subset of cases and in the recent SYNTAX-LE MANS study 2 >15% of implanted grafts failed at 15 months' follow-up.…”

“…Isolated ostial predivisonal stenosis of the left main coronary artery (IOSLM) is a rare form of coronary artery disease with peculiar pathologic and clinical features. 1 From a surgical perspective, IOSLM is a complex scenario in which coronary artery bypass grafting (CABG) has been reported to achieve suboptimal results 1,2 and there is no general consensus on the most appropriate conduits configuration. 3 Our institutions have traditionally adopted 2 different solutions in this setting: bilateral internal thoracic artery (ITA) grafts at St Luc Bouge and ITA on the left anterior descending (LAD) artery and saphenous vein (SV) on the circumflex system at Catholic University.…”