Chapter 52: What Is This? (2)

Anatomical variation was a term used to describe certain findings with a specific probability of occurrence. Typically, this probability ranged around ten percent or less. In other words, surgeons and medical practitioners could anticipate such variations to some extent when performing surgeries or procedures. Often, surgical techniques were developed while taking anatomical variations into account from the outset.

What…what are the odds of encountering something like this?

[The likelihood of both coronary arteries branching off as one from the aorta is less than 0.1%.]

And among those cases, how often does the right vessel branch so short while another bifurcation occurs on the left side?

[Based on my available data, there are no recorded statistics for this scenario.]

I don’t recall seeing this case report before.

[No, I have seen it once. Just one time.]

‘Ah…right.’

In other words, they were dealing with an extremely rare case right now. Even Suhyuk, who was merely assisting from behind, felt disconcerted, so Lee Hyunjong, directly responsible for the procedure, wanted to die of embarrassment.

Should I call thoracic surgery even at this stage?

He considered contacting them as he cautiously withdrew the guide wire that had been boldly inserted earlier. Despite the risk, he had aimed for the right coronary artery branch starting from just one blood vessel. However, the guide wire couldn’t progress beyond a mere 5 cm.

‘Ah…this is quite challenging.’

After all, who was Lee Hyunjong?

Lee Hyunjong was instrumental in advocating for the use of stents without open-heart surgery, challenging the long-held belief that thoracic surgery was always necessary. He even drew a comic strip depicting himself as an archer shooting blockages while cardiac surgeons wielded their scalpels, effectively promoting cardiology on a grand scale.

‘He is our nemesis.’

Indeed, since Lee Hyunjong became the hospital director, many thoracic surgery professors have avoided greeting him due to lingering animosity from academic rivalries.

‘What should I do now?’

Moreover, it seemed medically late to intervene at this point. As soon as he confirmed there was only one blood vessel involved earlier, he regretted not opting for immediate open-heart surgery.

“U-um, Dr. Lee.” At that moment, Suhyuk opened his mouth.

“Yes?”

“I’ll call thoracic surgery first. If there is a possibility of open-heart surgery, won’t they come?”

“Oh, would you do that? They will likely help if we don’t mention I’m currently operating. However…”

The situation wasn’t good at all. From the perspective of thoracic surgery, it might feel like receiving a patient who was already dead.

“Still, we need to call them. It’s too risky.”

“That…that’s true.”

“And…”

“And?”

“After making the call, I’ll immediately let you know their response.”

“Okay.”

Lee Hyunjong had just withdrawn the guidewire from the coronary artery back towards its origin near the aorta. He hesitated, contemplating whether to attempt another insertion or not when Suhyuk seemed to have something else to say, piquing his interest.

Suhyuk was contemplating whether to attempt it one more time instead of pulling back towards the aorta. When he noticed Lee Hyunjong’s interest, Suhyuk glanced at him and asked the nurse to make a call. Like any hospital, there was a hotline connecting the cardiovascular angiography room with the thoracic surgeon on-call, so the connection was immediate.

“Yes, sir. This is Dr. Lee Suhyuk from Internal Medicine, first year.”

“First-year doctor? Why? Is there an accident?”

The thoracic surgeons were also familiar with the number for the angiography room, so they never ignored calls even if it was from a first-year doctor.

Therefore, even if the caller was only in their first year, it couldn’t be ignored.

“It isn’t yet a CPR situation. However, there is an anatomical variation which makes it dangerous.”

“Variation? What…is it a blood vessel?”

“Yes.”

“But did you go inside? With a wire?” The person answering the phone was a fellow. In cases of variations with one blood vessel, it was common for thoracic surgery to handle it instead of internal medicine. Thus, his voice became slightly raised.

“Yes. I entered because the lesion wasn’t expected to be far from the blood vessel.”

“No, what kind of… Ah.” The fellow continued to suppress his anger as he recalled someone’s face. “By any chance, Professor Lee Hyunjong?”

“Yes.”

“Ah, sh…shit…I understand. I’ll head to the operating room. Please don’t do anything for now. How is the patient’s vital signs?”

“They are stable at present, but the blood pressure is low due to pre-existing right ventricular strain.”

“Yes. Understood. I will be there shortly. For now, please refrain from doing anything.”

“Okay.”

Suhyuk nodded, thinking Lee Hyunjong wouldn’t listen even if he said something. He then turned back towards Lee Hyunjong, who had been listening intently. Seeing his face, Suhyuk wondered whether he should continue this conversation.

“[The analysis has just finished. The dissection of this patient matches exactly with the case I have secured. Comparing it with the X-ray image currently displayed on the screen yields similar results].”

However, at the moment of hesitation, Baruda provided enormous courage to me. Of course, it didn’t mean I could open my mouth immediately.

‘Really, is it okay?’

[Suhyuk. In that case, he died while his chest was opened under similar circumstances. Perhaps if there had been a mediator present, he would’ve survived. Think about it. Open-heart surgery alone takes an incredible amount of time.]

‘Well, that’s true…’

Just preparing for the surgery would take around 30 minutes. Surgery couldn’t be performed simply by grabbing a knife and jumping in. Anesthesia needed to be administered, extensive disinfection required, and draping, as it was commonly called, had to be set up.

[You need to make a decision quickly. Time is passing even as we speak.]

In other words, it meant that the patient was dying. Suhyuk wasn’t a doctor with an insane sense of duty, but he still considered himself above average. With difficulty, he opened his mouth:

“Director Lee. May I offer my thoughts on this case?”

Although Suhyuk spoke these words, they were actually Baruda’s opinion. Lee Hyunjong, who had been contemplating whether to proceed or not, immediately nodded. A professor offering advice to a first-year resident - most professors wouldn’t consider such a thing, but Lee Hyunjong was highly adaptable. He had already broken through decades-old medical paradigms, so it was natural for him to encourage fresh perspectives.

“Go ahead. I called thoracic surgery, but…you know right? In this situation, open-heart surgery has over a 50 percent chance of death.”

“Yes, Dr. Choi. If we look at the case from University of California Irvine Medical Center in 1994, it shows the exact same anatomical variation.”

“University of California Irvine in 1994?”

“Yes.”

“Continue.”

The University of California Irvine was located near Los Angeles and was quite a good university. However, the hospital itself couldn’t be considered top-notch. In fact, its patient acceptance rate was lower compared to nearby medical centers. Despite these limitations, as a university hospital in the US, it maintained a certain level of quality.

“At that time, the patient was admitted to the emergency room with decreased consciousness due to right ventricular infarction.”

“It sounds similar to this case.”

“Yes, but back then, interventional procedures such as stenting were rarely performed. So, the patient was immediately transferred to the operating room for open-heart surgery and underwent coronary artery bypass grafting.”

“What happened?”

“By the time they arrived at the hospital, much time had already elapsed. Since we proceeded directly to surgery without conducting further tests, we couldn’t identify the anatomical variation beforehand.”

“Oh… I can see how it would have been confusing.”

Indeed, considering how baffling it was even with today’s advanced medical knowledge, one could only imagine how perplexing it must have been back then. Initially, everyone assumed the issue lay with the right-side blood vessels, yet unexpectedly discovered another vessel supplying blood to the right side of the heart.

“Yes. After her death, we received consent from the guardian for an autopsy to verify the anatomical structure, and it exactly matches this patient’s current condition.”

“So instead of a mutation…this is just a variation?”

“Correct. It is extremely rare but still a type of variation.”

“Then where should I go next?”

Lee Hyunjong advanced the guidewire slightly again. As he did, he noticed one branch heading right and another going left. Unlike typical variations, the left branch further split into two separate paths. The complexity made him wonder if someone was intentionally trying to torment the patient.

“It’s the branch on the left heading upwards.”

“Upwards? Not downwards?”

“The two branches intertwine slightly past here. The thicker part visible in this image is exactly where they merge.”

“Hmm.”

This meant he had to insert the wire opposite of what was initially apparent. Lee Hyunjong reflexively glanced at the clock behind him. It had already been over twenty minutes since the procedure began, which meant the patient was slowly but surely dying. With the blockage worsening, it was clear that any further delay would result in losing the patient entirely.

‘It definitely looks like the lower branch…’

But hadn’t he once been deceived by appearances, thinking it was clearly on the right side? There was no guarantee it wouldn’t happen again.

‘If he hadn’t mentioned the year, it would have sounded plausible.’

Lee Hyunjong might’ve let it go if Suhyuk had simply referred to some published case without specifying the year. However, mentioning ‘1994’ made it difficult for him to dismiss Suhyuk’s claim outright. Moreover, Lee Hyunjong already had immense trust in Suhyuk from their initial meeting.

‘Damn… At this point, trying his method gives us a higher chance of saving the patient.’

Had they approached this as cardiac surgery from the beginning, things might have been different, but that wasn’t the case now. With a resigned mindset, Lee Hyunjong pushed the guide wire forward.

Fortunately, one aspect working in his favor was his exceptional skill in maneuvering the guide wire, bordering on divine precision. Without any hesitation, he navigated the narrow coronary artery with ease.

Swish.

The guide wire proceeded towards the top but bumped against the wall once. Fortunately, due to its smooth tip and Lee Hyunjong’s gentle touch, there were no complications. The biggest reason for this was Suhyuk’s guidance.

“There, take a turn from there.”

Suhyuk promptly informed him about the anatomical structure.

“Y-Yes, truly remarkable. Good. Now, let’s not hesitate any further. Okay…”

Lee Hyunjong continued downwards, soon reaching the blockage. With each heartbeat, the blood vessels became visible using the previously injected contrast dye. At the location where the guide wire stopped, the blood vessel abruptly ended. This indicated the site of the obstruction.

“I have the stent.”

Suhyuk handed over the stent to Lee Hyunjong, whose face was filled with joy.

Lee Hyunjong laughed heartily as he pushed the stent along the guide wire.

“Hey, we did it! We saved the patient.”