A Case Based Discussion

1. Presenter: Dr. Azim Anwar
Phase-B Resident, Cardiology
BSMMU

2. Dr. Rasul Amin
ASSO. PROFESSOR & UNIT HEAD
(RED-2 UNIT) , BSMMU

3. Mr. Ibrahim Khalil,
59 Years
CCS III
DM (Uncontrolled)
3
On Query,
PCI to LAD on
March, 2021.
No Documents on
Stent details

4. Ongoing Management…………
▸ SAPT
▸ Statins
▸ PPI
▸ Bb
▸ Mononitrates
▸ S/L Nitrates
▸ Ramipril
▸ Nicorandil
▸ Ranolazone
4

5. Investigations
Trop I
CK MB NORMAL
S. Creatinine
HBA1C – 8.9
5

6. ECG : T inv in V1-V4
6

7. Echocardiography
▸ Anterior, A/S, A/L
▸ 40%
7

8. CCS III with
Refractory Angina
with Uncontrolled DM
CAG with Intend to
Revascularization

9. “ ▸ LAD –- T4. Stent
▸ Insitu in P & M.
9

10. “ ▸ ISR Pattern III
▸ Proliferative
10

11. “ ▸ .
▸ 60% ISR. dLAD 80%
11

12. “
12
■ OM 2 – 95%

13. “
13
▸ dRCA – Non
Critical

14. HOW TO TREAT ?
14

15. ISR Treatment
Type 1 : Balloon Angio/DEB
T 2/3/4: Restenting/CABG
(Sirolimus, Paclitaxel)

16. Head to Head Trial with Balloon Angio:
#Cutting Balloon
#Excimer laser angio
#Atherectomy
#Vascular brachytherapy
16

17. What to DO ?n Syntax Scoring ??
17

18. 18

19. In two or three columns
Yellow
Is the color of gold,
butter and ripe
lemons. In the
spectrum of visible
light, yellow is found
between green and
orange.
Blue
Is the colour of the
clear sky and the
deep sea. It is
located between
violet and green on
the optical
spectrum.
Red
Is the color of blood,
and because of this
it has historically
been associated with
sacrifice, danger and
courage.
19

20. 20

21. 21

22. 22

23. 23

24. 24

25. 25

26. 26

27. A picture is worth a
thousand words
A complex idea can be
conveyed with just a single
still image, namely making
it possible to absorb large
amounts of data quickly.
27

28. ISR, Why So Important ?
28
1 5
6
2
Balloon
Angioplasty
50%
Acute Recoil
& Acute
Vessel
Closure
DES <10%
Pharmaco
logical
supression of
Neointimal
Hyperplasia
BMS :
20-40%
Neointimal
hyperplasia
Whats Next
??

29. Definition of ISR
29
Typically 6-9 month
after, on followup
ancgiography
03
Either within the stent,
Or, 5 mm Prox or distal
to the stent margin.
02
Luminal Narrowing
of > 50%
01

30. Pathophysiology……
Early, < 3 months
Neointimal
Hyperplasia
Intermediate, 8-13
months:
Neointimal
Hyperplasia
30
Late, After Years
Very Early, <24 H
Acute Elastic
Recoil or
Plaque Prolapse.

31. In Stent Restenosis : RISK FACTORS
31

32. Procedural & Device Factors:
32

33. Procedural & Device Factors:
33

34. Procedural & Device Factors:
Stent
34

35. Procedural & Device Factors:
Stent
35

36. Procedural & Device Factors:
Stent Gaps
36

37. Biological Factors:
#Genetic Resistance to Rapamycin.
#Altered metabolism of Paclitaxel .
#Hypersensitive reaction to nickel, cobalt,
platinum, chromium.
37

38. Patient Factors:
#IDDM
#ESRD
#Small reference vessel diameter
#Long lesion length
#Ostial lesions
# Calcified Lesions
#Bifurcation lesion
# CTO
38

39. 39

40. Credits
▸
Special thanks to
Asso. Professor Dr. Rasul Amin
UNIT HEAD (RED-2 UNIT) , BSMMU.
And My Colleagues
40