Malpractice in Invasive Cardiology: Is Angiography of Abdominal Aorta or Subclavian Artery Appropriate in Patients Undergoing Coronary Angiography?

Simple and new technique to assess left internal mammary artery function by left ventriculography : LIMA imaging with ventriculography

The aim of this study was to demonstrate an assessment of left internal mammary artery (LIMA) patency and anatomy by standard left ventriculography, and to define a proposal for predicting LIMA function according to left ventriculography outcome. A total of 335 patients with an indication of coronary angiography were included. Standard coronary angiography and left ventriculography were performed initially. Visualization of LIMA occurred in the late phase of ventriculography and the LIMA visualization frame rate was counted for each patient. Then selective LIMA angiography was performed and LIMA diameter, LIMA course and anatomy, and subclavian artery anatomy were noted. Finally, the results of left ventriculography and LIMA angiography were compared by statistical analysis. During left ventriculography, LIMA was visualized in 96.4% of the patients. The mean LIMA visualization frame rate was 53.8 ± 17.7 and the mean LIMA diameter was 2.60 ± 0.36 mm. There was a strong correlation between LIMA visualization frame rate and LIMA diameter, LIMA course, and also asymptomatic subclavian artery disease (P < 0.001). Regression analysis showed that LIMA visualization frame rate is the major independent determinant for LIMA diameter prediction (P < 0.001); LIMA diameter, LIMA course, proximal LIMA side branch, and subclavian artery disease are the major predictors of LIMA visualization on left ventriculography (P < 0.001). LIMA patency and anatomy can be evaluated accurately with a simple method using left ventriculography. Besides direct visualization of LIMA, the visualization frame rate may constitute a reliable parameter for assessing LIMA function. A LIMA visualization frame rate of less than 50 is associated with a healthy and well-sized LIMA.

Prevalence and treatment of proximal left subclavian artery stenosis in patients referred for coronary artery bypass surgery

The left internal mammary artery (LIMA) is currently used in most coronary artery bypass graft (CABG) surgeries due to excellent long-term patency. Left subclavian artery stenosis (SAS) proximal to the LIMA origin can cause a steal syndrome leading to myocardial ischemia or LIMA failure. We retrospectively evaluated the records of 608 consecutive patients referred for CABG at our institution between October 1, 2004 and October 1, 2006 and identified 226 patients (37%) who underwent left subclavian angiography immediately after diagnostic coronary angiography. Significant left SAS was found in 6 of those 226 patients (2.7%). Subclavian angiography did not result in any complications. All left SAS lesions were successfully stented, followed by CABG surgery (using the LIMA artery) after 22+/-7 days. Left subclavian angiography in patients referred for coronary artery bypass surgery has low risk and may identify a small proportion of patients with significant proximal left SAS. Stenting of proximal left SAS can be accomplished before CABG with low risk and excellent short-term outcomes.

Whole-body MR vascular screening detects unsuspected concomitant vascular disease in coronary heart disease patients

Coronary heart disease (CHD) patients often show atherosclerotic vascular disease in other vascular territories. We evaluated how often whole-body MR imaging detects concomitant arterial pathologies in CHD patients, and how often these pathologies were not known to the patients previously. Of 4,814 participants in the population-based Heinz Nixdorf Recall Study, 327 reported CHD (i.e., previous coronary bypass surgery, angioplasty); of those, 160 patients (mean age 66.4 years) were examined using MR of the brain, the heart (excluding the coronary arteries), and whole-body MR angiography. The prevalence of each vascular pathology was assessed, correlated to the others and compared to patients' histories. Of the 160 CHD patients, 16 (10%) showed MR signs of stroke, and 77 (48.1%) had a stenosis >50% in at least one extracerebral peripheral artery (other than the coronaries), including 28 (17.5%) with relevant renal artery stenoses, and 20 (12.5%) with relevant extracerebral internal carotid artery stenoses. False negative histories were reported in 12 of 81 cases with myocardial infarctions, and in 11 of 16 cases with cerebrovascular infarctions. This whole-body atherosclerosis MR screening program allows previously unknown concomitant vascular disease to be detected in coronary heart disease patients. Its prospective value should be assessed in further studies.