Call for CASES Staged PCI in a patient with multivessel coronary disease disqualified from CABG....
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Transcript of Call for CASES Staged PCI in a patient with multivessel coronary disease disqualified from CABG....
Call for CASES
Staged PCI in a patient with multivessel coronary disease disqualified from CABG.
Pawel Buszman, MD, FESC, FSCAIMarcin Debinski, MDKrzysztof Milewski
American Heart of Poland, Ustron, Poland&
CCU, Upper-Silesian Heart CenterSilesian Medical School
Katowice, Poland
Staged PCI in a patient with multivessel coronary disease disqualified from CABG.
Pawel Buszman, MD, FESC, FSCAIMarcin Debinski, MDKrzysztof Milewski
American Heart of Poland, Ustron, Poland&
CCU, Upper-Silesian Heart CenterSilesian Medical School
Katowice, Poland
Introduction• PCI and CABG offer similar long term results (in respect to MI PCI and CABG offer similar long term results (in respect to MI
and death) in patients with moderately advanced coronary and death) in patients with moderately advanced coronary artery disease (CAD).artery disease (CAD).
• There are very few information on effectiveness of PCI in There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical patients with diffuse CAD and high risk of surgical intervention.intervention.
• Technological progress in interventional cardiology together Technological progress in interventional cardiology together with advances in pharmacology should result in better with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease. outcome in patients with end stage coronary artery disease.
• PCI and CABG offer similar long term results (in respect to MI PCI and CABG offer similar long term results (in respect to MI and death) in patients with moderately advanced coronary and death) in patients with moderately advanced coronary artery disease (CAD).artery disease (CAD).
• There are very few information on effectiveness of PCI in There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical patients with diffuse CAD and high risk of surgical intervention.intervention.
• Technological progress in interventional cardiology together Technological progress in interventional cardiology together with advances in pharmacology should result in better with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease. outcome in patients with end stage coronary artery disease.
Description of the problem
• Male, 76 years old
• Unstable Angina, class CCS IV
• Medical history: 2xMI (1994-nonQ anterior, 2003-inferior wall)
• CAD Risk factors: HA, family history, former smoker
• LVEF 40%
• EUROSCORE 13 points:
– age 4 pt
– unstable angina after AMI 2 pt
– peripherial atherosclerosis 2 pt– paroxysmal FA 3 pt– chronic obstructive
pulmonary disease 1 pt. – respiratory insufficiency 1 pt.
Description of the problemCoronary arteriography:
RCA: 60% stenosis in prox. RCA, 99% narrowing in med segment
LCA:
LM-diam. ca 3.5-4 mm, length 15mm,
LAD-30% prox.lesion; critical, long, calcified, tortous lesions in med and distal LAD,
Cx-90% type A lesion in prox, 99% type B2 lesion in distal segment.
RCA LAO60 LCA: RAO 30 LCA: LAO60/cran25
Intended strategy
• Multiple, stage PCI with continous control of previously dilated vessels/segments.
• Use of bare metal stents to minimize costs of procedures.
• Carefull evaluation of contrast volume used for each procedure and renal function before/after eache stage.
• Concomitant pharmacological treatment:ASA 150mg o.d., clopidogrel 75mg o.d.,ACEI, selective beta-blocker, statins,
First stage
Right coronary artery (RCA) in LAO 60, before and after PTCA.
Aug’2003: Predilatation of critical lesion in med RCA (balloon 3.0x20mm) and stenting of prox/med. segment (stent Chopin, Balton,
3.5x34mm, 18 atm). No complications. Hospitalization 6 days.
Second Stage
Fig 1. Left coronary artery (LCA) in LAO 60, before and after PCI to Cx.
Sept’2003: RCA: non-significant narrowings in med segments. PCI to Cx: POBA of distal lesion and predilatation and stenting of
prox lesion (Chopin 3.0x8mm, 18 atm.) No complications. Hospitalization 3 days.
Third Stage
Dec’2003: RCA: patent and large vessel, non-significant narrowing in med segments. Cx: restenosis in distal segment (75%).
PCI to LAD: predilatation (balloon 1.5x20 & 2.0x20mm) and stenting of med/distal LAD (Multilink Zeta, 18 atm.). VF during stent implantation, successfully defibrillated within 15 s (1x300W). No further resuscitation or intubation required.PCI to Cx: POBA of distal restenotic lesion (balloon 2.5x20mm), residual stenosis<30%.
Lab tests: Troponin I 1.04ng/ml; CK 337 U/l, CKMB 31 U/L.
Hospitalization: 4 days.
Third Stage
Fig 1. Left coronary artery (LCA) in LAO 60, before and after PCI.
Fourth Stage
LCA: RAO 30RCA: LAO 60 LCA: LAO20/cran25
March’2004: A control angio revealed patent coronary arteries without significant stenosis.
Follow-up
9 months after the first stage we noticed:• No significant stenosis in coronary arteries• LVEF improvement (55%)• Decrease of angina symptoms (CCS I)• Improvement in quality of live, NYHA class II• No further intervention requiered.
Further intensive pharmacological treatement:statins
beta-blockerACEIASA
Conclusions
• Stage PCI is a rational alternative to CABG in patients with advanced coronary artery disease and high risk of perioperative complications.
• In patients undergoing POBA or bare metal stent implantation a routine follow-up angio should be considered.
• Stage PCI offers opportunity to review previously dilated/stented coronary segments. It may limit obligatory use of DES.