You could learn more about cardiology courses with Prof. Sameh Allam by clicking on the courses’ library link here:

Objectives for this course:
1- Master the essentials of a successful complex PCI by using the radial approach
2- Essential questions on radial approach and the use of the specific radial device(s)
3- Clinical case strategy and radial approach limits
4- Anatomical variations in the Radial artery.
5- Master the essential steps of a successful radial procedure.

In this lecture, we will discuss “Coronary artery diffusion” and “the role of the aortic arch during TRA.

Coronary artery disease usually involves the proximal portion of the larger epicardial coronary arteries, but generally not their intramural branches. In most patients, atherosclerotic lesions in the coronary territory are segmental and eccentric, and they affect particularly bifurcations and sharp curvatures, whereas the rest of the long segments of coronary arteries are plaque-free. Diffuse coronary artery disease can be defined as the presence of multiple atherosclerotic stenoses or long-segment occlusions in the coronary territory. Atheromatous materials spread toward the distal and retain a long segment of coronary arteries which can obstruct coronary lumen “consecutive or longitudinal” and “complete or partial”.

Most of the patients with diabetes, hyperlipidemia, chronic renal insufficiency, connective tissue disease, heart transplantation, and multi-stented coronary arteries have diffuse atherosclerotic lesions in the coronary territory. All of these diseases affect and accelerate coronary arteriosclerosis differently.
Restenosis after first CABG can also be a reason for the diffuse coronary atherosclerosis, but usually, these patients have ungraspable diffuse diseased coronary vasculature and none of the specific revascularization methods can be used.

Diffuse atherosclerosis has been highly widespread among patients with coronary artery disease in the last two decades because simple lesions are usually treated with stent interventions in the early phase of coronary pathology.
Diffuse coronary lesion and reduced coronary flow reserve can be silent due to several collaterals, but it might result in severe functional limitation, chronic low-level ischemia, and myocardial remodeling.
Low-level ischemia can be a potential driver of both first coronary vasomotor and myocardial dysfunction, and then remodeling in heart failure with preserved ejection fraction. Diffuse atherosclerosis and microvascular dysfunction-associated coronary artery disease comorbid conditions may guide new, more effective, aggressive, and therapeutic interventions for global cardiovascular risk reduction due to complete revascularization.
There is no difference in event-free survival between CABG or stent implantation in patients with high coronary flow reserve; however, CABG is significantly more effective than stent in patients with low coronary flow reserve.

The diffuseness of coronary artery disease is a serious risk factor for early and late adverse events after coronary revascularization, but the acceptable strategy should be complete revascularization.
Standard bypass method (finding an appropriate lumen and performing anastomosis) is usually not possible in the diffusely diseased coronary arteries, and such a region, which may be found at most distal, cannot be expected to bring any benefit.
For this reason, in such cases, it is required to apply a complex method other than the standard bypass method.
When the atherosclerotic stenosis is local, it is technically possible and easy to revascularize the distal segment directly, but in diffuse coronary artery disease or in the presence of diffuse stenotic regions, different techniques should be implemented for complete revascularization.

The treatment of the diffused-type coronary artery disease has always been an issue; however, this scenario is challenging for cardiac surgeons because diffuse atheromatous lesions frequently render epicardial coronary vessels unsuitable for conventional distal grafting.

However, there are some strategies to perform a complete revascularization with increasing complexity and mortality risk sequentially in these patients.
Second, to attenuate or prevent perioperative infarction and/or postischemic ventricular dysfunction caused by inadequate myocardial protection, there are many different administrative ways for cardioplegic solutions, but the optimal delivery method of cardioplegia also remains controversial.
Off-pump bypass can be another option when the coronary artery is totally occluded and retrograde flow supplies the myocardium.

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