Three-Vessel Coronary Artery Disease
This patient has three-vessel coronary artery disease. The angiogram demonstrates significant obstructive disease in all three major coronary territories: the LAD (80% stenosis), the LCx (chronic total occlusion), and the RCA (chronic total occlusion). 1
Vessel-by-Vessel Analysis
The classification of multi-vessel disease counts each major epicardial coronary artery with significant stenosis (≥70%) or total occlusion:
- LAD territory: 80% stenosis in the tightest segment represents severe obstructive disease 1
- LCx territory: Total occlusion of the distal LCx to PDA constitutes complete vessel involvement despite the proximal segment being only mildly ectatic 1
- RCA territory: Chronic total occlusion of the proximal RCA represents complete vessel involvement 1
The 30% left main stenosis is non-obstructive and does not alter the vessel count, as left main disease is classified separately when stenosis exceeds 50%. 1 This patient does not meet criteria for left main equivalent disease, which requires ≥70% stenosis of both the proximal LAD and proximal LCx. 1
Clinical Significance and Classification
This represents CAD-RADS 4B (three-vessel obstructive disease) with two chronic total occlusions, placing the patient at extremely high risk for adverse cardiovascular events. 1 The presence of CTO in non-infarct-related arteries significantly increases 12-month mortality risk (relative risk 1.42) in patients with three-vessel disease. 2
The ACC/AHA guidelines classify three-vessel disease as a Class I indication for coronary artery bypass grafting, particularly when left ventricular function is impaired (ejection fraction <0.50). 1 The survival benefit of CABG over medical therapy alone is most pronounced in patients with three-vessel disease and abnormal left ventricular function. 1
Critical Management Considerations
Immediate referral for surgical revascularization is warranted given the extent of disease involving all three major coronary territories with two chronic total occlusions. 1 Percutaneous intervention has limited success with CTO lesions and carries high restenosis rates compared to surgical revascularization. 3
The presence of proximal LAD involvement (80% stenosis) combined with three-vessel disease represents the highest-risk anatomic pattern for adverse outcomes and derives the greatest survival benefit from CABG. 1, 4