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One stage coronary and peripheral intervention

One stage coronary and peripheral intervention. P awel Buszman, MD , American Heart of Poland , Ustron Silesian Medical School, Katowice. Case report. Clinical data Male, 72 year old Unstable angina (CCS class 4) TIAs

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One stage coronary and peripheral intervention

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  1. One stage coronary and peripheral intervention Pawel Buszman, MD, American Heart of Poland, Ustron Silesian Medical School, Katowice

  2. Case report Clinical data • Male, 72 year old • Unstable angina (CCS class 4) • TIAs • RISK FACTORS:-heavy smoker(30 cigarettes a day)-hypercholesterolemia

  3. Case report • EKG:ST depressions in inferior leads • UKG:normal LV function

  4. Coronary and peripheral angiography ICA 99% CCA AP: aortic bifurcation and iliac arteries LAO30: left CCA and ICA

  5. Coronary and peripheral angiography LM: 80% stenosis 90% LCA: RAO30 RCA: RAO30

  6. Strategy of the procedure • Predilatation and stenting of mid. RCA • Direct stenting of LM • Predilatation and stenting of left ICA • Kissing stenting of aortic bifurcation

  7. PTCA: RCA stenting 6F guiding catheter Predilatation: balloon 2.5 mm Stent: Bx Velocity 3.0x18mm Max pressure 14 atm. RCA after stenting

  8. PTCA: LM-stenting Guiding Catheter JL6F Wire: BMW 0,014” Stent: BX Velocity 3.5x18mm Max. pressure 20 atm

  9. Carotid stenting Long Sheath 7F Wire: BMW 0,014” Pre-dilatation: balloon 3.5 mm Stent: SMART 7x20mm Post-dilatation: balloon 4.5 mm

  10. Kissing stenting of aortic bifurcation Bilateral, retrograde approche through 7F sheats. Direct stenting: 2xWallstent 10x45mm Postdilatation:balloons 2x8.0mm

  11. Procedure protocol • 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.

  12. 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

  13. 6 month control coronary angiography: Stented segment LCA: RAO30

  14. 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!

  15. The substantial risk of:-AMI-sudden cardiac death-stroke-critical limb ischemia-surgical treatment -cardiac surgery -vascular surgery The risk of-LM stenting&restenosis-carotid stenting-renal failure-in-stent restenosis Why a percutaneous procedure?The patient’s risk summary Pro Contra

  16. Risk of stroke • In symptomatic patients with severe narrowing of a common or internal carotid artery annual risk of stroke range between 20-30%

  17. Coincidence of CAD and PAD • 30-50% of patients with PAD have coronary artery disease

  18. 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.)

  19. Influence of PAD on long-term survival PAD Detection, Awareness, Treatment and Primary care. JAMA 2001;286:1317-1324.

  20. Prognosis in patients with severe PAD one-year mortality rate • Critical inferior limb ischemia 25% • An inferior limbamputation 45%

  21. 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.

  22. Conclusions • Drug eluting stents should enhance the safety of LM stenting.

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