Challenging case presentation recorded at Cardiovascular Innovations 2017.
Welcome from cbi 2017 i’m dr. michael luna here with dr. sahar a smell from emory she’ll be presenting hop skip and a stent overcoming peripheral disease in high-risk pci whoa all right thank you for having me so we’re gonna present the case from our va we have a 64 year old gentleman with the history of coronary disease ckd hypertension hyperlipidemia insulin
Dependent diabetes who was referred for an outpatient left heart cath her worsening angina he had a left heart cath back in 2004 which showed some disease and the distal left 2 main as well as a lady had significant disease in the mo mo um as well as a subtotal occlusion in the mid rca most recent echo he had an ef of 30 to 40% with some posterior wall of kinases
And moderate amar has been in terms of medications she was pretty optimized she was on a beta blocker a long-acting nitrate and ranolazine who is also on high-intensity stan ace and low dose aspirin in terms of labs done a presentation his grandin was at baseline 1.56 1.57 his troponin was 0.05 and cbn p was high of 421 and this is the left heart cath at that
Time which showed he had pretty significant left main lesion with to 60% on site as well as a 90% left circuit lesion his right showed that she had that cto that we saw back in 2004 so the patient was referred to ct surgery for bypass unfortunately after the left heart cath he became hypoxic workup showed that he had of aspiration pneumonia who was intubated
For a few days he received a full course of that antibiotics and then while he was sitting on the floor waiting for to go to the o arm he had the fib cardiac arrest and then was taken urgently to the cath lab his ekg showed that didn’t really show significant st changes he didn’t mr. foreman was 0.38 and his crown was at baseline so we initially were trying to
Do a right radial approach he had a lot of edema and the right to arm and there was a lot of temps to put in a line we couldn’t really access the right arm left arm had persistently low blood pressures and the right arm so we were worried about it locks up cleaning stenosis we went for the left but we couldn’t pass the wire left femoral so then we went to the
Right and we shot the right in we saw that he had pretty significant disease and has left common iliac and right external iliac so a platinum plus 0.01 8 wire was advanced and we used a 7 by 20 balloon following that we then performed things we performed cyril dilatation over an impasse extra stiff 0.035 wire and 14 french sheath was inserted and then we put
Them pellissippi on in geography he had a new occlusion of the om and left circ was thought to be the cause of his cardiac arrest we then with a 7 french jl 3.5 guide catheter we engaged the left main and then we used a choice b tes to cross the om lesion we then did multiple dilatations with a sprinter balloon 2.5 by 20 we then tried to pass a 2.5 by 38 promis
Stent but we couldn’t pass it at the woman’s love to assert bifurcation because of severe calcifications so then we took the guide wire guideline her further down the left sirkin to the proximal left desert to kind of provide us some more support and then we did some further dilatation with an nc sprinter as well and then we went back in with a promise 2.5 by 20
We were able to extend from right at the tip of the om distally and then we took another stunt as well to point 2 point 7 5 by 8 approximately we did a run through guide wire was inserted into the led and he had pretty significant disease here was looking at an iris of the led with an area of four millimeter square we also did ivis of the pox left circ and he
Had pretty significant disease of the left search so we also put in a stent 2.75 by 8 as well on the box of circa we then used the ng sculpt balloon was inserted over the led wire into the left main and the led and we ballooned it a few times and put in at 3.5 by 28 promess stent we post dilated with an nc sprinter balloon and then we also put in a whisper wire
Down the left circ a followed by an nc truck balloon and we balloon down simultaneously according to their kissing blowing technique and then these are our results so another human and then we did i this the left main afterwards there’s some mild position so we did some further ballooning as well and and when you’re gonna do this sort of intervention do you have
Any consideration for doing angiograms from up above the subclavian and the nominative arteries just so you get the lay of the land in case something goes awry when you’re doing the intervention of the iliac and you’re unable to support the patient over there yeah that’s a good point and it would have been a good thing to do in this patient as well i think you
Know by the time we were you know we had them peloton and we’re going proceeding with the case it was you know about an over an hour into the case and aphasia one has hypotensive so at that point we were just trying to get in there and fix it but that is a it’s a very good point and and as your as your ex planting the the impella device i’m assuming you explanted
This at the time after the intervention is there any consideration for a performing angiogram of the iliac that you just interviewed on to see if you have to descent at that point or just leave it be so at the time we left it be i think it was more because if he had ckd and got a ton of contrast but again you know it’s the patient dependent yeah you you here
We wanted to show that the is our that the wire was truly in in the sub loom intimal space rather than through the stent and we showed the stent the true the strength was in the true lumen but the irish katsura was in the sub intimate space so that’s what we wanted to show here but we don’t routinely use it thank you
Transcribed from video
CVI2017 Challenging Casey – Sahara Ismail, MD By Cardiovascular Innovations
