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Evaluation of flow in the left anterior descending coronary artery but not in the left internal mammary artery graft predicts significant stenosis of the arterial conduit

Francesco Pizzuto, MD^*,*, Paolo Voci, MD, PhD^*, Enrica Mariano, MD, Paolo Emilio Puddu, MD, FESC, FACC, Alessandro Aprile, MD and Francesco Romeo, MD, FESC, FACC

^* Cardiology
Cardio-Thoracic and Vascular Sciences "A. Reale," "La Sapienza" University
Department of Cardiology, "Tor Vergata" University, Rome, Italy

View larger version (162K): [in a new window]   Figure 1 Selective coronary angiography of the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD). (Upper panels) Competitive flow without graft restriction. (A) Injection in the LIMA. The empty arrow points to the joining tract, where flow entering from the LIMA is stopped by non-contrasted blood coming from the proximal LAD. (B) Injection in the left main shows anterograde filling of the LAD. (Lower panels) Competitive flow with graft restriction. (C) The dye selectively injected into the LIMA partially fills the graft, which is thin (arrows) and does not allow the contrast to reach the joining tract. (D) Contrast injection in the left main shows anterograde filling of the LAD, with 30% middle tract stenosis (empty arrow).

View larger version (151K): [in a new window]   Figure 2 Resting transthoracic color-Doppler ultrasound. (A to C) Patient without competitive left internal mammary artery (LIMA) graft flow. Color Doppler (A) shows LIMA and left anterior descending (LAD) flows (arrows), and corresponding pulsed Doppler ultrasound shows prominent diastolic velocity (B and C). (D to G) Patient with flow competition. The LIMA flow (D and E) shows a prominent systolic and a very low diastolic component, whereas LAD flow (F and G) is mainly diastolic.

View larger version (93K): [in a new window]   Figure 3 Patient with occluded proximal left anterior coronary artery (LAD), without competitive left internal mammary artery (LIMA) flow. The flow velocity reserve (CFR) was similar when assessed either at the level of the LIMA (empty arrow), or at the level of the LAD (white arrow).

View larger version (112K): [in a new window]   Figure 4 Patient without competitive left internal mammary artery (LIMA) flow, occluded proximal left anterior descending coronary artery (LAD), and 80% distal, post-anastomotic LAD stenosis. The coronary flow reserve (CFR) in the LIMA is 3.7, whereas in the distal LAD it is 1.5.

View larger version (135K): [in a new window]   Figure 5 Patient with flow competition. (Upper panels) Flow velocity in the left internal mammary artery (LIMA) shows a higher systolic than diastolic component and a markedly abnormal coronary flow velocity reserve (CFR). (Middle panels) CFR, measured in the distal left anterior descending coronary artery (LAD), was normal. (Lower panels) Coronary angiography showed that the LIMA was proximally patent, but contrast material stopped at the joining tract. There was no flow limiting stenosis in the distal LAD after the anastomosis.