Any proof of ischemia in the LAD (mid-distal segments, Apex)?

If yes and no other explanation the LIMA side branch could be easily coiled.

Samer Mansour

It is most important to severe all side branches of LIMA while mobilizing it from chest wall.

I performed coil embolization of great branches of LIMA in 3 patients with angina after coronary revascularization. The procedures is  easy and safe. in all patients the angina were solved. 

The usual branch missed is the first branch after take off, as shown in the angio here. Usually missed by the assistant and not checked by boss - leads to another procedure another expense.

Ask you interventionalist to coil the side branch. As Dr. Gupta has already stated this is  a surgical miss due to incomplete take down of the LIMA. Of course it is more cumbersome in the apex of the toracic cavity but you need to make sure that you have ligated the first intercostal.

I think better way for this kind of problem side branch should be ligat with coil via intervention angioplasty because he has chest pain. Thank you 

In front a personal similar situation ,interventionalist put a coil with immediate and safe result.

A proof of ischemia in the LAD territory should preceed any further intervention. If so, I would also recommend an interventional closure of this really big side branch. As already pointed out, this problem should be avoided by a meticulous take down of the IMA, of course including the ligation of the first intercostal branch!

Thanks to everyone for your valuable opinion

I totally agree with all the previous opinions. No doubt a coil placement seems to be feasible and safe, but any proof of ischemia in distal LAD territory should be obtained before. 

But let me ask some questions about medical therapy and blood pressure levels? Coronary steal is sometimes favoured by vasodilator drugs through lowering perfusion pressure leading to more distal ischemia. 

I think you should be sure that the cause of angina i the steal from LIMA branch. Did you exclude distal disease in distal coronary arteries or microvascular diseas? You should have a proof of ischemia in the territory of LAD, and then it should be easy to close the LIMA branch with a coil.

the cardioligy should be able to close with a coil

Be sure that the anginal pain is due to LIMA steal.

try to keep BP in high normal side 

maximize B blocker and use metabolic anti angina like trimetazedine

if you are sure from the steal effect avoid nitrate

First, may be is necessary to do a SPECT test to demonstrate ischemia. Seconda, you can close the artery by a coil.

I agree with all of the above. Other than a coil, you could deploy a covered stent in the LIMA as well, occluding the side branch.