TRANS-RADIAL PRIMARY PCIIN A PATIENT WITH 3-VESSEL CAD
PRESENTED WITH ACUTE INFERIOR STEMI AND CARDIOGENIC SHOCK
Bambang Budiono, MDHeart & Vascular Center
Awal Bros Makassar HospitalIndonesia
Primary PCI : Trans-femoral vs Trans-radial
Transradial Primary PCI :
Less access Bleeding Complication
(up to 80% reduction)
does not prolong door-to-ballon time,
And improve clinical outcome
Bleeding Complications
Advances in antiplatelet and anticoagulant therapies in patients with ACS undergoing PCI potentially increase bleeding complications.
Bleeding associated with increase risk of mortality, recurrent MI and strokeTherefore, Transradial PCI is
a default strategy in ACS
TR-Primary PCI : The limitations
Limited guide catheter size (could be solved with sheathless GC)
Not palpable Radial artery
Renal failure on haemodyalisis
In patients with Cardiogenic shock (need IABP insertion)
Transradial primary PCI is even acceptable in
Cardiogenic shock, when the use of both IABP and ECMO,
is needed Simultaneously
Clinical History:
A 55 Y.O male, was referred from other private hospitalpresented with typical angina > 1 hour, diaphoresis, bradycardia, and hypotension(BP: 75/50 mmHg, HR : 45 bpm), unconsious.
PMH : SAP (CCS 2) since > 1 year & positive TMT, not keen to undergo coronary angiography
Traditional risk factors : Heavy smoker, DM Type II
Laboratorium result : Hb : 13 g/dl, Platelet : 292 .103/ulCreatinin : 0.9 mg/dlRandom Blood Sugar : 225 mg/dlLDL : 66 mg/dl, HDL: 35 mg/dl
ECG : ST elevation : II, III, aVF (no ST elevation at V3R, V4R)
The Strategy
GP2b/3a inhibitor (Integrillin)Vasopressor + Inotropic
IABP ?Temporary Pace Maker ?
Primary PCI: Transfemoral !
Dobutamin 5 ug/ kg bw/mntNorepinefrine 0.05Ug/ kg bw/mnt
BP : 75/50 mmHg HR : 46 bpm
BP : 105/60 mmHg HR : 75 bpm
Watchful waiting forIABP insertion
CoronaryAngiogram
RAO – Caudal View
LAO – Cranial View
LAO – Cranial View
Trombus aspiration using a 6 Fr Thrombuster
Trans-Radial primary PCI
GC : 6 Fr TR4, GW : Pilot 50
1st - Stage
First Stage
GC : a 6 Fr TR4GW : Pilot 50 0.14”
XIence Prime Stent : 3.0x23 mm
After Thrombo-aspiration Direct Stenting
Final Result
Door to Timi-3 Flow time : 35 minute
Procedure Time : 20 minute
Contrast Volume : 60 CC ( Dx & PCI)
After PCI
Before PCI
ECG : BEFORE AND AFTER PCI
Points to discuss with the patient
A diabetic Patient with small and long lesion in LADEcho : LVEF : 63 %SYNTAX SCORE : 29.5EURO SCORE : 2 ( Mortality : 1.51%)
Options :
1. Off/ on Pump CABG : LIMA to LAD – RIMA/ left radial to OM2. Hybrid procedure : LIMA to LAD , DES/BVS to prox.
3. Second stage PCI to LCX and LAD (DES or BVS) √
PTCA ke II
3-DAY AFTER2nd-Stage PCI
LCX- 1st attempt
GC : a 6 fr BL 3.5
GW : a 0.014” Runthrough NS hypercoatDirect Stenting : Xience Prime 3.0x12 mm ( 14 atm)
3-DAY AFTER 2nd-Stage PCI
LAD-2nd attempt
Mid LAD totally occluded
0.014” Runthrough Hypercoat GW (SB)
0.014” Pilot 150 GW, crossing CTO
Predilatation : Minitrek 1.5x12 mm
Minitrek 2.0x15 mm
Replace GW : Pilot 150 with
Runtrhough NS HC 0.014”
Stent : Xience Prime 2.5x38 mm
Stent Xience Prime 2.5x18mm After Post Dilatation : NC 2.5x15 mm
Final Result
Summary :
Trans-radial primary PCI was successfully done in a patient with 3 vessel CAD presented with Acute inferior STEMI complicated with Cardiogenic shock who well respond with vasopressor and inotropic drugs. Lesions in the LAD and LCX was staged 3-day afterward.
The patient was discharged on 5th day without any symptom. Laboratory result showed no renal impairment despite episode of cardiogenic shock before PCI.
Conclusion
Performing trans-radial primary PCI in STEMI with CS withoutthe use of mechanical haemodynamic support is doable ingood responder (to vasopressor/ inotropic agent) patients.
Rapid reperfusion is the key of success to stabilize Haemodynamic in patients with CS caused by AMI
However, decision of choosing the access site for Primary PCI, should be based on careful clinical judgment,
and experience of cathlab Staffs and operators.