ACI 2018 Best of the Young - PPCI in a Shocked Patient with Complex Anatomy - Ahmad Shoaib

1. PPCI IN A SHOCKED PATIENT WITH
COMPLEX ANATOMY
DR AHMAD SHOAIB
DR KARIM RATIB
PROF MAMAS A MAMAS
ROYAL STOKE UNIVERSITY HOSPITAL
STOKE ON TRENT

2. Clinical presentation
• 72 year old, Male, HTN, heavy smoker
• Severe chest pain for last 4-6 hours
• ECG: 3-4 mm ST segment elevation in V1-V5
• Presented in RSUH through PPCI pathway
• Haemodynamically unstable- BP 80/40 mmHg
• Transferred to Cath lab
• RRA, 6 F Sheath, EBU 3.5 Guide catheter
• SBP dropped to 40 mmHg on cannulation of LMS
• Cardiac arrest and needed several cycles of CPR
• IABP through RFA

3. Coronary angiogram

4. LMS equivalent disease in severely calcified vessels in a shocked
patient
?Urgent CABG/PCI/Rotational atherectomy/Lazer
Cutting balloon was not available in lab
?Guidelines for this high risk patient
?Expected complications of any approach
CTS contacted and they advised to continue PCI

5. Ballooning of LAD/LMS (2-2.5-3 mm balloons)

6. PCI to LCX

7. PCI TO LAD

8. Poor expansion of heavily calcified lesion just proximal to mid
LAD stent -treated with angiosculpt balloon and schwarber NC
balloon at 40atm

9. PCI to LMS and LAD

10. Emergency PCI for perforation in LAD
parapyrus 3.5 X 15 mm & 4 X15 MM covered stents

11. Post dilatation with 4 X 15 non compliant balloon

12. Mission accomplished

13. CONCLUSION
• Complex CAD anatomy with heavy calcification is challenging in PPCI
setting in Cardiogenic shock patients
• Optimal strategy for revascularization is not clear in guidelines and
research evidence is limited
• We are not certain which approach is better form
CABG/PCI/Lazer/Cutting balloon/Rotational atherectomy in these complex
clinical settings
• High proportion of complications like perforations are expected in this
high risk cohort
• Successful PCI is technically possible despite all of these challenges
• More prospective research is needed to increase body of evidence