Dear Hoque,

Thank you for interesting question. Sorry, undoubtedly I don't know the problem in complex. Why do not you consider traditional angioplasty: balloon dilation with consecutive coronary stent inserting in the most stenotic parts of CA?

Hi Hoque,, very interesting and relevant question. Now a days we get a quit good number of patients who fall in this category. Management is often difficult.

However few treatment options are available ....like

Spinal cord stimulation

Endoscopic thoracic sympathetomy

Thoracic epidural anaesthesia

Transmyocardial and percutaneus myocardial lessar revascularisation

Stem cell therapy

Enhanced counter pulsation

Some newer pharmaceutical treatment is also under evaluation... They are.. Selective I f calcium channel blockers and fatty acid metabolism inhibitor. Among all these spinal cord stimulation llB and level B recommendations according to AHA/ACC..thanks

These are terrible patients with low survival and fast progression to CHD. The most important factor in deciding the revascularization strategy is territory viability, especially of the anterior (LAD) territory. Regarding surgical revascularization, if at all graftable and without major contraindications for arterial harvesting, I would use total arterial revascularization on viable territories. Most people would use vein grafts due to the probable low survival of these patients but arterial revascularization would give them a better survival chance due to graft favourable characteristics... however, this is a personal opinion, since studies on best revascularization strategy in this subset of patients are not abundant...

If the surgical team thinks that the coronary arteries are not graftable,either the coronary arteries are too small in calibre or the disease is diffuse.In the latter-one valid option is a reconstruction of coraonry arteries. Please refer to my paper".Extensive Coronary Artery Reconstruction (ECAR) – A New Paradigm for Diffuse Coronary Artery Disease – Early Analysis Article Jan 2011 · Heart, Lung and Circulation Rajiv Sharma · Antonio Xabregas · Robert Tam"

We have used Enhanced counterpulsation with reasonable success.

https://www.nepjol.info/index.php/NHJ/article/view/8343

First of all if the vessels are very bad on angiography CABG should not have been done. These patients will gain very little from the surgery and the surgery is risky for them so not doing the surgery should be an option. Another issue that if they do have angina an attempt could be done to perform s PCI on a possible culprit lesion with some control of their angina. If the patient has left main stem disease than angioplasty for that stenosis may be attempted. Otherwise these patients are very difficult to treat. Ivrabidine, ranolazine and trimetazidine be helpful.

We had a series of 13 patients, 2 of them was post CABG, none of then had options of revascularization surgically. None of the lesion was amenable to angioplasty or stent. All had significant reversible ischemia on Tc 99 myocardial perfusion scan.

We offered then Coronary sinus reducer device. A significant number of patients improved their symptoms with improvement on follow up perfusion scan. Few later relapsed and were offered spinal cord stimulator.

Not worth mentioning that we optimized and maximized medical therapy before we offered them intervention.

Data will be published.

Thanks everybody for enlightening me. It is a difficult clinical scenario and the management modality should preferably be individualized. The options are many but none is satisfactory. We would have to select one to provide the best support for the patient. Thanks everybody for opening up all the possibilities to choose one from.