Ostial occlusion of all epicardial coronary arteries: Living off bypass grafts.

OBJECTIVE

To evaluate clinical profile and coronary perfusion of patients with ostial occlusion of all epicardial coronary arteries.

METHODS

Between 2009 and 2025, 165 adults (mean age, 72 ± 9.8 years; 92% male [n = 152]) with prior coronary artery bypass grafting (CABG) had complete ostial occlusion of the right coronary artery (RCA) and either the left main (n = 120; 73%) or left main equivalent (n = 45; 27%). One additional patient without prior CABG presented in cardiogenic shock and was bridged to transplantation. Graft patency and collateralization (Rentrop and collateral connections scores) were assessed by angiography and ischemia, and scar burden was evaluated by stress positron emission tomography (n = 89).

RESULTS

Of the 165 patients, 88 (53%) presented with symptoms related primarily to ischemia, 67 (41%) presented with symptoms related primarily to heart failure, and 19 (12%) were asymptomatic. Sixty-four of 89 patients (72%) had positive stress imaging. Of 64 patients with a patent internal thoracic artery to the left anterior descending artery (LAD) and had positron emission tomography tests, 9 (14%) showed scar only, 25 (39%) ischemia only, and 19 (30%) with both. Collaterals supplied the LAD, circumflex, and RCA territories in 50, 83, and 100 patients, respectively, with the LAD receiving collaterals from the RCA in 28 of the 50 (56%). The 233 collaterals included 103 (44%) with Rentrop grade 1 (filling without epicardial vessels); 81 of 165 patients (49%) had complete vascularization (patent grafts or high-grade collaterals to all territories). Postdiagnosis, 14 patients (8.4%) underwent CABG, 50 (30%) underwent percutaneous intervention, and 100 (61%) received medical management, with median survival of 7.6, 6.0, and 3.0 years, respectively (P = .027).

CONCLUSIONS

Patent bypass grafts can sustain survival in patients even after ostial occlusion of all epicardial coronary arteries, an advantage not previously reported by other coronary disease therapies.