One stage coronary
and
peripheral intervention
P. Eugeniusz Buszman, MD
American Heart of Poland
Ustron, Poland
Case report
Clinical data




Male, 72 year old
Unstable angina (CCS class 4)
TIAs
RISK FACTORS:
-heavy smoker
(30 cigarettes a day)
-hypercholesterolemia
Case report
EKG:
ST depressions in inferior leads
 UKG:
normal LV function

Coronary and peripheral angiography
ICA
99%
CCA
LAO30: left CCA and ICA
AP: aortic bifurcation
and iliac arteries
Coronary and peripheral angiography
LM: 80% stenosis
90%
RCA: RAO30
LCA: RAO30
Strategy of the procedure
1.
2.
3.
4.
Predilatation and stenting of mid. RCA
Direct stenting of LM
Predilatation and stenting of left ICA
Kissing stenting of aortic bifurcation
PTCA: RCA stenting
6F guiding catheter
Predilatation: balloon 2.5 mm
Stent: Bx Velocity 3.0x18mm
Max pressure 14 atm.
RCA after stenting
PTCA: LM-stenting
Guiding Catheter JL6F
Wire: BMW 0,014”
Stent: BX Velocity 3.5x18mm
Max. pressure 20 atm
Carotid stenting
Long Sheath 7F
Wire: BMW 0,014”
Pre-dilatation: balloon 3.5 mm
Stent: SMART 7x20mm
Post-dilatation: balloon 4.5 mm
Kissing stenting of aortic
bifurcation
Bilateral, retrograde
approche through 7F
sheats.
Direct stenting:
2xWallstent 10x45mm
Postdilatation:
balloons 2x8.0mm
Procedure protocol
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






No of guiding catheters:
2
No of balloons
4
No stents
5
No of wires:
2
No of arterial sheats
4
Contrast volume
350 ml (non-ionic)
X-ray exposition
19,5 min.
Procedure time
110 min.
Periprocedural outcome and
long-term follow-up
No procedure related complications
 48 hour hospital stay
 Normal renal function
 No recurrence of myocardial ischemia or
TIA during 6 month follow-up
 Normal daily activity

6 month control coronary
angiography:
Stented segment
LCA: RAO30
Discussion

Why one-stage procedure?

Unstable angina requiring myocardial
revascularization
High risk surgical candidate
Critical ICA narrowing with TIAs
Risk of the inferior limb ischemia after
the arterial sheath removal
Repeat access to heart to be maintained!




Why a percutaneous procedure?
The patient’s risk summary
Pro

The substantial risk of:
-AMI
-sudden cardiac death
-stroke
-critical limb ischemia
-surgical treatment
-cardiac surgery
-vascular surgery
Contra

The risk of
-LM stenting&restenosis
-carotid stenting
-renal failure
-in-stent restenosis
Risk of stroke

In symptomatic patients with severe
narrowing of a common or internal carotid
artery annual risk of stroke range between
20-30%
Coincidence of CAD and PAD

30-50% of patients with PAD have coronary
artery disease
Major cardiovascular events in patients
with PAD – 5 year follow-up

AMI, UA, Stroke
20%

Death
20-30%
(PAD Detection, Awareness, Treatment and Primary care.
JAMA 2001;286:1317-1324.)
Influence of PAD
on long-term survival
PAD Detection, Awareness, Treatment and Primary care. JAMA 2001; 286:1317-1324.
Prognosis in patients with severe
PAD
one-year
mortality rate
Critical inferior
limb ischemia
 An inferior limb
amputation

25%
45%
Conclusions

Long term survival after myocardial
revascularisation can be limited by severe carotid
and peripheral artery disease.

Cardiac cath lab should be prepared for a
peripheral intervention.

Interventional cardiologists should be routinely
trained in those procedures.
Conclusions

Drug eluting stents should enhance the
safety of LM stenting.