This document describes the case of an 82-year-old man with chest pain and pulmonary edema who was found to have multi-vessel coronary artery disease including a distal left main lesion. Due to his advanced age and high surgical risk, percutaneous coronary intervention (PCI) was chosen over coronary artery bypass grafting (CABG). The staged PCI procedure involved initially stenting the right coronary artery, followed by a complex multi-stent strategy including a mini-crush stent for the left main lesion and additional stents in the circumflex and left anterior descending arteries. The final result demonstrated successful revascularization.

1. Rencontres Interventionnelles - Transradial Approach
Prague, Czech Republic,
Thursday 29th & Friday 30th September 2011
Special Mediterrannean session
Distal LM, MVD, TRA, elderly patient
Dr
Faouzi
Addad
Professor
of
cardiology
Department
of
cardiology-­‐
University
hospital
A.
Mami-­‐Ariana-­‐Tunisia
1

2. PaEent
Male, 82 years old
Risk factors
• Hypertension
• dyslipidemia
Clinical past History
• None
Life style
• Active lifestyle
vendredi,
octobre
7,
2011
2

3. Clinical Presentation
Sudden onset of chest
pain with a severe
pulmonary oedema
BP:90/60 mmHg
invasive ventilation during
24 hours
ECG: anterior ST
segment depression
vendredi,
octobre
7,
2011
3

4. Baseline
Angiography
by
right
TRA
leG
coronary
angiography

5. Baseline
Angiography
leG
coronary
angiography

6. Baseline
Angiography
Right
coronary
angiography

7. LeG
Main:
Anatomic
characterisEcs
Distal
locaEon
>70%
Calcified>50%
cases
cases
MulEvessel
Disease>70%
cases

8. Risk
Evalua8on
Euroscore
Euroscore=26,79% Very high risk for surgery

9. high
risk
of
MACCE
at
one
and
three
year
SYNTAX Score=30

10. Bleeding
risk
evaluaEon

11. Crusade
bleeding
risk
score
and
the
major
bleeding
rate
29,3%
13,3%
30
14
23,9%
25
22%
12
10
20
8
15
12,7%
12,2%
3,8%
4%
6
10
4
2
0%
0%
5
0
0
34,2% are at high or Incidence of major
very High risk of bleeding at hospital
bleeding according to Crusade
score
ROC curve: r=0.889
SCA Ariana Registry

12. Key
points
• SymptomaEc
82
male
• Non
diabeEc
• Distal
leG
main
disease
(superficial
calcificaEon)
• Lesion
in
osEal
and
proximal
Cx
• Lesion
in
proximal
LAD
• Type
A
lesion
of
proximal
RCA
• Very
High
surgical
risk
• Intermediate
Syntax
Score
• High
risk
of
bleeding
• High
risk
of
CIN

13. Key
issues/strategy?
• PCI
vs
CABG?
• Which
strategy
for
LM
PCI
and
MVD?

16. Key
issues/strategy?
• PCI
vs
CABG?
• Which
strategy
for
LM
PCI
and
MVD?

17. PCI
dilemmas
A/
Type
of
stent?
• Bare
metal
Stent?
Vs
Drug
eluEng
stent?
B/
Size
of
sheat?
• 6
or
7
F
C/
Access
route
for
PCI
• Femoral
approach?
• Radial
approach?
D/
Could
i
treat
this
pa8ent
without
IVUS-­‐guided?

18. We choose a BMS for clinical reasons: Bleeding risk and problem
of compliance for DAPT (during one year) and for economic reasons:
only 2 stents/patient are reimbursed

19. What
is
the
best
strategy
for
PCI?
• RCA
PCI
first?
• LMD
disease
First?
• In
one
and
two
Emes?

21. RCA
PCI
first
two
days
aGer
the
first
angiogram
(Right
TRA)
Right TRA: Direct stenting: Stent BMS: integrity 3.5 X 15 mm at 16 atm

22. PCI
for
LMD
and
mild
LAD
• Programmed
aGer
10
days
by
Right
TRA
• 1
stent
or
two
stents?
• If
two
stents:
T
stenEng,
crush
stent,
mini
crush
stent,
culode
stenEng,
V
stenEng,
Y
stenEng?

23. Single
vs
two
stents?

25. The lesion of Circ is one of the key elements for the strategy
of Left Main PCI.

26. Proximal
LAD
PCI
Direct stenting
Integrity 3.5 X 15 mm at 16 atm
2 BMW wires
Plavix 300 mg + aspirine 100 mg + UFH 60 UI/Kg

28. Minicrush
stenEng
Compliant balloon
2.0 X 15 mm at 10
atm
there is no consensus on the best option for elective stenting with 2 stents

30. Stent
deployment
in
the
osEum
of
Cx
Stent Driver
2.75 X15 mm at 12 atm

32. StenEng
of
LM
Driver
4.0 X 12 mm

33. Deployment
at
16
atm

34. Result
aGer
the
stent
deployment

36. Two-step Kissing Balloon post-dilation

37. Non
compliant
ballon
at
20
atm

39. Final
result
aGer
the
Kissing
Balloon

40. Final
result
aGer
the
Kissing
Balloon

43. Conclusions
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7,
2011
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2011
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