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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 Pawel 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 • 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 AP: aortic bifurcation and iliac arteries LAO30: left CCA and ICA
Coronary and peripheral angiography LM: 80% stenosis 90% LCA: RAO30 RCA: RAO30
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
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 • 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!
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
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 25% • An inferior limbamputation 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.