Posts Tagged ‘distal lad’

IRA localization for both LAD and RCA , LCX  is a fascinating  exercise for cardiologists.I suspect  our understanding  about this crucial issue is  far from complete .While  localizing  level of lesion within LCA  or RCA requires more precise data and erring is acceptable  , it is not uncommon to  call  even the  IRA wrong  especially in multi -vessel disease.

Why current   criteria of IRA localisation goes awry many times  ?

The  factors  that operate are not few   . . .  it  runs into a dozen  at least  !

  1. Dominance  is never considered during IRA localization  (A right dominate system can vastly influence the LAD localization  algorithm PLV branches  can protect LV postero- lateral segments in spite of proximal LAD lesions )
  2. The length of  mid LAD   IS  controversial entity ( Traditionally  it refers  to  the  segment  between first major diagonal to second  major diagonal or septal  leads to faulty   coronary mensuration .It is not uncommon to have a  mid LAD measuring few  mm  when  full the full  length of  LAD  is about 15-19cm
  3. Diagonal vs OM  trade off occurs  in every alternate patient which is ignored  !
  4. Ramus  is never considered worthy enough  to be included in the IRA  localization scheme (In spite its presence  in 20 % )
  5. Type of LAD is not given allowance.
  6. Finally &  most importantly these rules of IRA localization will not apply in  the setting of  multivessel  CAD
  7. In the presence of Pre existing CTO
  8. STEMI following chronic stable angina
  9. Extensive collaterals
  10. Re Infarctions
  11. Post CABG etc

Final message

Decide for yourself  . . .  how good is the value of IRA localization  after  considering all the above variable. . It is not a great thing to predict  correctly RCA from LCX in an  inferoposterior MI  with a  70 % accuracy  . (It actually means  20 % accuracy  )    statistically when there are only two options  . . .  we are blindly  right 50% of times   !

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Proximal LAD lesions require  specific and early Intervention.Hence we need to know what exactly  we mean by proximal LAD disease.Unfortunately , it means different things to different cardiologists .There is no dispute regarding the  origin of  LAD since it begins with bifurcation point  .The problem comes with  this question !

Up to what distance LAD can be termed as proximal ?

  1. Bifurcation  to   “First   diagonal” of  any size
  2. Bifurcation  to   “First Major diagonal”
  3. Bifurcation to     “First septal”  of any size
  4. Bifurcation to    “First  major septal”
  5. Bifurcation  to   “Any major  first branch ” (Either septal or diagonal )

Answer : I think  4 is the correct answer . But many believe  5 can be correct as well !

Why  there is  confusion in the  definition of proximal LAD ?

This is because the first branch of LAD itself is not a  constant one  . It can either be a septal  or  uncommonly  a diagonal.

It should be noted , the septal and  the diagonal  branches  neither respect   seniority  nor follow a  hierarchy .The first diagonal may be diminutive while the   second or third diagonal may be major one  and vice versa .Further  ,  there can be a trade of  in length and caliber of   septal and diagonal branches  .This  phenomenon is also  common between  diagonals  and   OMs  . All these confound the picture .

Cardiologists even though they are  primarily physicians they are  pro-anatomy  like surgeons when it comes to coronary interventions .

                                  In the strict sense ,  we  need to differentiate a  lesion  from being   physiologically proximal  or anatomically proximal  !

Is there a proximal LAD equivalent ?

There are three  situations  this can occur .

  • Some times a lesion  by  definition may not fit in  as proximal  LAD  but physiologically  few major diagonals  will arise after the lesion.
  • Other situation is , LAD lesion may be  mid or distal but  a major first  diagonal may be diseased  , making it  equivalent  to proximal LAD in terms of physiology.
  • A mid LAD  with a large OM lesion which is running in the D1  territory

Final message

It is ironical  millions of cardiology interventions happen  for proximal  LAD lesions  every year without  even  proper understanding of what we mean by  it ! Youngsters are argued to ponder  over this issue whenever  they indulge in  such cases for revascularisation!


Text books differ in their definition about proximal LAD. Currently , the  SYNTAX  scoring system  has defined the coronary segments in a practical way.


Definition from SYNTAX

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Coronary artery disease has a strong   predilection  to involve proximal segments.

But in a significant population it affects only the distal vascular bed ! What is the extent of this problem ?

This paper was presented in  the annual sessions of Cardiological society of India , Mumbai 2005

Down load presentation


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