Vanishing Collaterals Immediately Post-Percutaneous Coronary Revascularization

Abstract

A 74-year-old gentleman with history of diabetes mellitus, hypercholesterolemia, tobacco use and prior myocardial infarction, was admitted via the emergency room due to unstable angina. He had sustained a lateral non-ST elevation myocardial infarction 6 years earlier, when he was submitted to percutaneous coronary intervention (PCI) and stenting of the obtuse marginal branch of the left circumflex coronary artery, considered the culprit lesion and during the same session, stenting was also performed of a stenosis of borderline angiographic significance of the left anterior descending (LAD) coronary artery. During his current admission, urgent coronary angiography was performed, which revealed a total proximal occlusion of the LAD (panel A, arrow); full collateral supply of the LAD was noted from the right coronary artery (panel B, arrows). A significant proximal lesion of the right coronary artery was also detected (not shown).The patient consented to an attempt to revascularize the occluded vessel via PCI, which was successfully accomplished with implantation of 3 coronary stents (panel C, thick arrow). Successful direct stenting was also performed of the proximal lesion of the right coronary artery. Upon completion of the PCI procedure, contrast injection of the right coronary artery revealed the disappearance of the collateral vessels supplied to the LAD (panel D, dashed arrows). Echocardiographic examination showed a near-normal systolic function of the left ventricle (ejection fraction ~55%).