Call for CASES

1
Call for CASES

• Staged PCI in a patient with multivessel coronary
  disease disqualified from CABG.
• Pawel Buszman, MD, FESC, FSCAI
• Marcin Debinski, MD
• Krzysztof Milewski
• American Heart of Poland, Ustron, Poland
• CCU, Upper-Silesian Heart Center
• Silesian Medical School
• Katowice, Poland

2
Introduction

• PCI and CABG offer similar long term results (in
  respect to MI and death) in patients with
  moderately advanced coronary artery disease
  (CAD).
• There are very few information on effectiveness
  of PCI in patients with diffuse CAD and high risk
  of surgical intervention.
• Technological progress in interventional
  cardiology together with advances in
  pharmacology should result in better outcome in
  patients with end stage coronary artery disease.

3
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.

4
Description of the problem

• Coronary 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.

LCA RAO 30
RCA LAO60
LCA LAO60/cran25
5
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 treatmentASA 150mg
  o.d., clopidogrel 75mg o.d.,ACEI, selective
  beta-blocker, statins,

6
First stage
Aug2003 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.
Right coronary artery (RCA) in LAO 60, before
and after PTCA.
7
Second Stage
Sept2003 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.
Fig 1. Left coronary artery (LCA) in LAO 60,
before and after PCI to Cx.
8
Third Stage
Dec2003 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 stenosislt30. Lab tests
Troponin I 1.04ng/ml CK 337 U/l, CKMB 31
U/L. Hospitalization 4 days.
9
Third Stage
Fig 1. Left coronary artery (LCA) in LAO 60,
before and after PCI.
10
Fourth Stage
March2004 A control angio revealed patent
coronary arteries without significant stenosis.
RCA LAO 60
LCA LAO20/cran25
LCA RAO 30
11
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
treatementstatins beta-blocker ACEI ASA
12
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.