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Posts Tagged ‘homocollaterals’

A middle aged man who owns a petty shop in a small  town of south India   came to us for stable angina .His RCA looked like this.

Normally if one coronary artery is obstructed the other comes to the rescue .It seems , this RCA do not trust it’s sibling LAD . See how it  self supports  its own  territory .(The most fascinating and mysterious aspect of coronary circulation is the collateral circulation. LAD  has big brother attitude  . . . it hesitates to help others while   RCA is more philanthropic , we know  it sends prompt  collateral to  LAD  whenever it is  distressed !)

However , there is one advantage of  such   self-sustenance of RCA  (Intra coronary/homo-collaterals ) . If  the  RCA  has to live  at the mercy of LAD  it  runs a risk of   neglect  at times of  distant LAD ischemia as well  !

Management

Single vessel disease , total occlusion , long segment lesion , still  the  PDA  is protected and the vital postero- basal area of heart perfused well ! What to do ?

Scientific  cardiologists  would like to meddle this  RCA with  multi-pronged guide-wires and other weapons  . Non -scientific cardiologists would  send him  home with medicines  . This patient preferred the later ! In the process  he  saved a  lakh ,  which  I  believe was meant for his daughter’s  education . He profusely thanked me for not hijacking his hard earned money for  frivolous  reasons . I said he should thank  his collaterals  and not me , for getting his money back  !

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Sharing and caring for  others  is the  unique human nature . Some believe this is  now gradually   becoming  rare in human domain ,   but still  found in plenty among  animal species. While modern human  likes to live independently  wants to stand on his own legs  our  biological system still  think differently .

A 40-year-old man with diabetes and hypertension with class 3 angina had this angiogram

RCA to LAD collaterals

A different view

RCA to LAD in RAO caudal view

See , how a  pair of  human coronary arteries  mutually  help   their  colleague  at times of distress !

The astonishing observation is ,  the  RCA even as its suffering  with  a severe,   long segment disease it  helps out-of-the-way ,  with a long arm  of  support to  the entire LAD . While , the LCX reciprocates  the RCA by sending  thank you twigs to distal RCA

LCX sending reciprocating twigs to RCA

By the way , this patient was referred  for CABG after an   intense  debate in the cath meeting  .The argument ranged from medical management /PCI/CABG.

The key question were

  • How good is the collateral’s and what  are the chances of  graft flow  exceeding the collateral  blood flow ?
  • What is the effect of CABG on the existing collateral’s ?

Final message

Coronary arteries  has unique sense of sharing and friendship at times of vascular crises.

This is the fundamental basis for   coronary collateral circulation .

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