One stage coronary and

peripheral intervention

P. Eugeniusz Buszman, MDP. Eugeniusz Buszman, MD

American Heart of PolandAmerican Heart of Poland

Ustron, PolandUstron, Poland

Case reportClinical dataClinical data

Male, 72 year old Male, 72 year old Unstable angina (CCS class 4)Unstable angina (CCS class 4) TIAsTIAs RISK FACTORS:RISK FACTORS:

-heavy smoker-heavy smoker(30 cigarettes a day)(30 cigarettes a day)-hypercholesterolemia-hypercholesterolemia

Case report

EKG:EKG:ST depressions in inferior leadsST depressions in inferior leads

UKG:UKG:normal LV functionnormal LV function

Coronary and peripheral angiography

LAO30: left CCA and ICA AP: aortic bifurcation and iliac arteries

99%

CCA

ICA

Coronary and peripheral angiography

RCA: RAO30

90%

LCA: RAO30

LM: 80% stenosis

Strategy of the procedure

1. Predilatation and stenting of mid. RCA2. Direct stenting of LM3. Predilatation and stenting of left ICA4. Kissing stenting of aortic bifurcation

PTCA: RCA stenting

RCA after stenting

6F guiding catheterPredilatation: balloon 2.5 mmStent: Bx Velocity 3.0x18mmMax pressure 14 atm.

PTCA: LM-stenting

Guiding Catheter JL6FWire: BMW 0,014”Stent: BX Velocity 3.5x18mmMax. pressure 20 atm

Carotid stenting

Long Sheath 7FWire: BMW 0,014”Pre-dilatation: balloon 3.5 mmStent: SMART 7x20mmPost-dilatation: balloon 4.5 mm

Kissing stenting of aortic bifurcation

Bilateral, retrograde approche through 7F sheats.Direct stenting:2xWallstent 10x45mmPostdilatation:balloons 2x8.0mm

Procedure protocol

No of guiding catheters:No of guiding catheters: 22 No of balloonsNo of balloons 44 No stentsNo stents 55 No of wires:No of wires: 22 No of arterial sheatsNo of arterial sheats 44 Contrast volumeContrast volume 350 ml (non-ionic)350 ml (non-ionic) X-ray expositionX-ray exposition 19,5 min.19,5 min. Procedure timeProcedure time 110 min.110 min.

Periprocedural outcome and long-term follow-up No procedure related complicationsNo procedure related complications 48 hour hospital stay48 hour hospital stay Normal renal functionNormal renal function No recurrence of myocardial ischemia or No recurrence of myocardial ischemia or

TIA during 6 month follow-upTIA during 6 month follow-up Normal daily activityNormal daily activity

6 month control coronary angiography:

LCA: RAO30

Stented segment

Discussion

Why one-stage procedure?Why one-stage procedure?

Unstable angina requiring myocardial Unstable angina requiring myocardial revascularizationrevascularization

High risk surgical candidateHigh risk surgical candidate Critical ICA narrowing with TIAsCritical ICA narrowing with TIAs Risk of the inferior limb ischemia after Risk of the inferior limb ischemia after

the arterial sheath removalthe arterial sheath removal Repeat access to heart to be maintained!Repeat access to heart to be maintained!

Why a percutaneous procedure?The patient’s risk summary

The substantial risk of:The substantial risk of:-AMI-AMI-sudden cardiac death-sudden cardiac death-stroke-stroke-critical limb ischemia-critical limb ischemia-surgical treatment-surgical treatment

-cardiac surgery-cardiac surgery-vascular -vascular

surgerysurgery

The risk ofThe risk of-LM stenting&restenosis-LM stenting&restenosis-carotid stenting-carotid stenting-renal failure-renal failure-in-stent restenosis-in-stent restenosis

Pro Contra

Risk of stroke

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

Coincidence of CAD and PAD

30-50% of patients with PAD have 30-50% of patients with PAD have coronary artery diseasecoronary artery disease

Major cardiovascular events in patients with PAD – 5 year follow-up

AMI, UA, StrokeAMI, UA, Stroke 20%20%

DeathDeath 20-30%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 one-year mortality ratemortality rate

Critical inferior Critical inferior limb ischemialimb ischemia 25%25%

An inferior limbAn inferior limbamputationamputation 45%45%

Conclusions

Long term survival after myocardial Long term survival after myocardial revascularisation can be limited by severe carotid revascularisation can be limited by severe carotid and peripheral artery disease.and peripheral artery disease.

Cardiac cath lab should be prepared for a Cardiac cath lab should be prepared for a peripheral intervention.peripheral intervention.

Interventional cardiologists should be routinely Interventional cardiologists should be routinely trained in those procedures.trained in those procedures.

Conclusions

Drug eluting stents should enhance the Drug eluting stents should enhance the safety of LM stenting.safety of LM stenting.