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
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.
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
– paroxysmal FA
– chronic obstructive
pulmonary disease
– respiratory insufficiency
2 pt
3 pt
1 pt.
1 pt.
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.
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
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.
Right coronary artery (RCA) in LAO 60, before and after PTCA.
Second Stage
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.
Fig 1. Left coronary artery (LCA) in LAO 60, before and after PCI to Cx.
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
March’2004: A control angio revealed patent
coronary arteries without significant stenosis.
RCA: LAO 60
LCA: RAO 30
LCA: LAO20/cran25
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-blocker
ACEI
ASA
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.