To help understand the following coronary artery angiogram from our patient, a diagram of the left coronary artery and its main branches in the cranial left anterior oblique view is shown. After a short course, the left main coronary artery typically divides into two vessels - the left anterior descending and the circumflex arteries. The major branch of the left anterior descending is the diagonal artery. The major branch of the circumflex artery is the obtuse marginal artery.
Our patient
This is a still-frame from our patient's angiogram. It demonstrates a high-grade proximal stenosis of the left anterior descending coronary artery proximal to the first septal perforator that also involves the diagonal branch. In the real-time study that follows, note the poor flow in the left anterior descending coronary artery distal to the obstruction.
Coronary angiogram
The coronary angiogram in our patient revealed a 95% stenosis in the left anterior descending coronary artery prior to the take-off of the first septal perforator; a 95% stenosis at the origin of the diagonal branch of the left anterior descending was also identified. No thrombus was seen. Revascularization by pertutaneous coronary intervention, or PCI, was recommended for both of these lesions.
Our patient - post angioplasty
This is a still-frame of our patient's angiogram done after revascularization. It demonstrates lumen enlargement and good distal flow in both the left anterior descending and its diagonal branch. The real-time study follows.
PCI
Percutaneous coronary intervention is commonly used for myocardial revascularization. Acute complications are relatively infrequent, and include abrupt vessel closure and dissection that may lead to myocardial infarction.
The major limiting factor is restenosis. The use of stents to hold the vessel open reduces the incidence of restenosis in comparison to angioplasty alone. Drug-eluting stents offer decreased restenosis rates in comparison to bare metal stents. The addition of a potent inhibitor of platelet aggregation, such as clopidogrel, also reduces the likelihood of in-stent thrombosis.
Discharge
Our patient's hospital course was uncomplicated. At the time of discharge, he was instructed to continue his beta blocker, nitroglycerin, ACE-inhibitor, warfarin and statin. He was started on clopidogrel, a potent inhibitor of platelet aggregation, that improves the patency rate of the bare metal stent. Because he needed both warfarin and clopidogrel, he was not started on aspirin at this time. He was advised to continue his health maintenance program and return for close follow-up evaluation. It is important to continue clopidogrel for at least one month when using a bare metal stent and even longer periods when using a drug-eluting stent.
Interval evaluation
When seen for a one-month follow-up visit, he was doing very well, had resumed his exercise program and was symptom free. His clopidogrel was discontinued and he was restarted on aspirin.