CASE20210723_001
High Risk Angioplasty in ACS-Not Every Case is the Same
By
0
Presenter
Punish Sadana
Authors
1
Affiliation
, India1
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention
High Risk Angioplasty in ACS-Not Every Case is the Same
1
, India1
Clinical Information
Patient initials or Identifier Number
JP
Relevant Clinical History and Physical Exam
A 72 year old male a known case of hypertension,Diabetes
mellitus type 2 ,chronic obstructive pulmonary
disease,nephropathy presented to ER with complaints of
chest pain (left side) radiating to jaw and left arm for 2
days .There was also history of breathing difficulty for 2
days.
On examination: Rest pain present
:Pulse rate 110/min,BP 136/94mmhg
Chest : Bilateral crepitations
CVS S1S2 normal
Spo2 86% at room air
Per abdomen/CNS examination was within normal limits
Relevant Test Results Prior to Catheterization
Blood examination: Troponin I 0.7Creatinine 1.7ECG:ST-t changes in precordial leadsEcho RWMA in LAD territory,LVEF 32%
Relevant Catheterization Findings
Coronary angiography revealed Triple vessel disease:Left Main distal 50%plaque,osteal LAD 100%blocked,osteal LCX 50%plaque,mid 90%sttenosis,mid RCVA 100%blocked.
Interventional Management
Procedural Step
As it was a high risk angioplasty with two 100%occluded vessels, IABP was inserted beforehand.Left system was hooked with 7F EBU 3.5 guide catheter,LAD lesion crossed with Fielder XT r guidewire with micro catheter support and lestion predilated with 2x15 and 2.5x15mm balloon. While dilating the balloon inproximal LAD LCX got otally occluded(?thrombus) and patient started complaining of chest pain, LCX was immediately crossed with floppy guidewire and flow achieved.Mid LCX and Mid LAD lesion was fixed using 2 DES.Left Main bifurcation stenting was planned using minicrush technique.While pushing LCX(proximal Stent) stent, it got dislodged in guiding catheter which was retrieved using small 2mmm balloon inflated distally,theterafter bifurcation stenting done using 2 DES.Patient was discharged the 3rd day on dual antiplatletes.
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1. High-Risk Angioplasty is defined as angioplasty in patient with multiple comorbidities, poor LV functtion or hemodynamics or with high risk anomical features like large amount of myocardium is supplied by stenosed vessels, diffusely calcified vessels, left main disease, bifurcation stenosis and CTO.
2. To avoid hemodynamic compromise support devices like IABP should be used.
3. Do not push, pull stent against resistance,keep the guiding catheter coaxial and always chech stent balloon integrity once out of guiding catheter.
4. For dislodged stent opions available are retrieval, deployment or crushing against the vessel wall(not in left main case)
5. Imaging is very important in such cases