The document summarizes a case study of a high bleeding risk patient who required urgent PCI prior to orthopedic surgery. The patient had multiple vessel disease including chronic total occlusions. The interventional cardiologist performed complex PCI using dual guidewires and drug-coated stents, which allowed for a shortened dual antiplatelet therapy duration of 1 month prior to surgery. The case highlights the importance of an individualized approach for high bleeding risk PCI patients, including consideration of drug-coated stents to balance risks of bleeding and restenosis.

1. 19th & 20th November 2016
Fairmont Hotel, Jakarta
www.isicam.org
INDONESIAN SOCIETY OF INTERVENTIONAL CARDIOLOGY ANNUAL MEETING
PCI in High Bleeding Risk
Isman Firdaus
Interventional Cardiologist Consultant
Pusat Jantung Nasional Harapan Kita, Indonesia

2. 19th & 20th November 2016
Fairmont Hotel, Jakarta
www.isicam.org
INDONESIAN SOCIETY OF INTERVENTIONAL CARDIOLOGY ANNUAL MEETING
 I have the following potential conflicts of interest to report:
 Research contracts
 Consulting
 Employment in industry
 Stockholder of a healthcare company
 Owner of a healthcare company
 Others
 I do not have any potential conflict of interest
Speaker name: Isman Firdaus, MD, FIHA, FAPSIC, FAsCC, FESC, FSCAI

3. • At Least 20% of PCI patients are High Bleeding Risk
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Rittger H et al. Herz 2014;39(2):212-8
Faxon et al. Circ Cardiovasc Interv 2011;4:522-34
De Biase et al. Transl Med 2015;11(3):14-23
To et al. Circ Cardiovasc Interv-2009;2:213-21
Wiviott et al. NEJM 2007;357:2001-15
Pilgrim et al. Circ Cardiovasc Interv. 2012;5:202-210
Shanmugam VB et al. Journal of Geriatric Cardiology 2015;12:174−184
Urban P. et al. Am Heart J 2013;165:704-9

5. CASE 1:
• Male, 48 yo
• History of PCI 4 DES in 2008
• Hospitalized for ORIF surgery due to fibula and tibial fractures in
Jakarta Private Hospital
• Aspilet was stopped for 7 days by Orthopedist

6. • 2 days before surgery, patient was sufferred refractory progressive
angina
• Refractory heart failure
• Orthophedist and Cardiologist preffered for early PCI
• Refferred to PJN Harapan Kita

8. PJN Harapan Kita
• Planned for Early PCI
• Angiogram showed
• LM : Irregularities
• LAD : Irregularities with severe In stent, difuse and long stenosis from proximal
to mid part. Distal part was total occlusion due to stent failure
• LCx : Irregularities with difuse and subtotal occlusion at prox-distal part
• RCA : Irregularities with severe and diffuse stenosi, Chronic total occlusion at
proximal part

9. Dx/
• NSTEMI (very high risk profile)
• CAD 3 VD , RCA and LAD CTO
• Fibula-tibial Fracture planned for non
cardiac surgery

10. RCA ANGIOGRAM LCA ANGIOGRAM

11. •Operator incharge decided to suspend PCI and planned
for CABG
•Heart Team Conference (intervensional Cardiologist,
Cardiac surgeaon, Orthopedist, and Cardiac Intensivist)
 preffered for PCI than CABG

12. Difficulties in Decision and Technique
• Cardiac Surgeon reffused for CABG
• Complex and advance PCI
• Culprite or target vessel in dual CTO lession
• DAPT consideration, required non cardiac surgery (ORIF)

13. Strategy and Technique
• Single vs Dual Guide  JR 3.5/6F and XB 3.5/6F
• Antegrade vs retrograde  XTA wire
• Femoral vs radial
• 1st line wire selection : Fielder (XT-A vs XT-R) vs non-Fielder family
• Stent selection : BMS vs DES vs DCS
• Stent selection was very important to Reduced the duration of DAPT
after PCI

14. Fielder XT-A for Channel tracking

15. Fielder XT-A for Channel tracking
Balloon 1.25/15 for
Channel crossing

16. Balloon 1.25/15
Balloon 2.0/20
Angiogram After top
up ballooning

17. DCS 2.75/36
DCS 3.5/26
DCS 3.5/18

18. BEFORE AFTER

19. balloon 2.0/20
POBA LAD

20. LCx PCI : DCS 2.75/36

21. After PCI
• Refractory angina and heart failure was relieved
• He required 1 mo duration of DAPT : Ticagrelor 2 x 90 mg
and Aspilet 1 x 80 mg
• Underwent successful major surgery ORIF without any
complication

23. High Bleeding Risk Requires Individual Approach
DCS
(Drug Coated Stent)
(3-6 Mo DAPT) (12 Mo of DAPT)
1-3 Mo DAPT
Reduced Bleeding risk
Reduced restenosis risk