Cath Lab Digest

A 65-year-old gentleman presented to us with severe substernal chest pain within an hour of gastric bypass surgery. The patient’s risk factors include morbid obesity, hypertension, hyperlipidemia and positive family history of heart disease. The patient is 5’9” and 330 pounds. His EKG shows nonspecific ST and T wave changes. At the time of presentation, his enzymes were not back, and there were no acute changes on his electrocardiogram. His troponins were positive and this was treated as a non-ST elevation myocardial infarction.

The first question is, “do you catheterize this gentleman who is nearly 200 pounds overweight via the right groin or use the radial technique?” His angiogram revealed him to have good LV function with mild inferior hypokinesis and an ejection fraction of 60%. The right coronary had a 99% occlusion. The left main was free of disease. The left anterior descending coronary artery (LAD) had a high-grade diagonal stenosis and a 70% LAD stenosis with an 80% ramus stenosis and the circumflex was occluded with right to left collaterals. The patient had 3-vessel coronary disease. He was not diabetic. Would he best be treated with intervention or with bypass? Secondly, what does it mean when a patient presents with an acute coronary syndrome and has a chronic conclusion of a non-ischemic vessel? Thirdly, if PCI is performed, do you do this all at one time or do you do this in a staged procedure?

The answer is that we did treat the patient with his acute coronary syndrome via the right radial artery. Angiomax^® (The Medicines Company, Parsippany, New Jersey) was started and the right coronary stenosis, which we felt was the ischemic producing lesion, was approached with a 2.0 Ikari guide (Terumo, Somerset, New Jersey), and the FielderXT wire (Abbott Vascular, Abbott Park, Illinois). When we placed a 3.0 x 12 mm Endeavor^® stent (Medtronic, Minneapolis, Minnesota) distally and a 3.0 x 30 mm proximally, the stenosis went from 70% to 0% proximally and 99% to 0% distally. The patient was treated with prasugrel and recovered nicely. Twenty-four hours later, the patient presented with chest pain again with some elevated troponins but no EKG changes. This time we went through the left radial artery with a 2.0 Ikari guide. We crossed the LAD stenosis and placed a 3.0 x 12 mm Endeavor stent and the ramus was then treated with a 3.5 x 9 mm Endeavor. The LAD diagonal was felt to be too small for intervention so we decided to not approach this or the circumflex CTO.

Since this procedure was done on March 29, 2011, the patient has been asymptomatic. However, questions remain: (1) Do you treat the chronic total occlusion of the circumflex? (2) If so, when do you treat it? and (3) Should the patient undergo surgery? Again, the patient is still morbidly obese, and he is not diabetic. In terms of his likely success long term, he will have a higher chance of restenosis and reintervention with drug-eluting stents then surgery, but less likely to have complications associated with bypass in a morbidly obese gentleman (i.e. infections, etc.) so he underwent successful recanalization of chronic total occlusion of the circumflex artery. This was done via the right radial artery 2 months after the original presentation. We used a 2.0 Ikari guide (Terumo) and crossed the lesion with a Provia wire (Medtronic, Minneapolis, Minnesota) and performed balloon angioplasty and placement with a 3.5 x 24 mm Endeavor stent.

This case raises several questions: (1) When a patient has an acute coronary syndrome and has a total occlusion of one of the vessels, what is his prognosis? From a recent study in the Netherlands, his prognosis is very poor at 30 days, as well as at 5-year follow-up. Based on this, he is best treated with something because his prognosis without treatment is undesirable. (2) What about a patient who has just undergone a major operative procedure who is again almost 200 pounds overweight and what about the performance of acute coronary bypass in a patient in this subset? In this case, we felt it was better treated by percutaneous intervention simply because all the lesions were approachable, including the chronic total, which in our hands can be successfully treated with a 90% success rate. Lastly, the patient had all these procedures done radially, which is easier in a morbidly obese patient. Recently, the RIVAL study showed that with experienced physicians, the likelihood of a major cardiac event is less compared with the groin procedure in sites such as ours that are very experienced in radial procedures.

Cases like this will be discussed at our meeting at the Wynn Encore Hotel in Las Vegas on September 9–10, 2011. At this meeting Ron Waksman and Michael Mack will be discussing 3-vessel coronary disease and its therapy in regard to the context of the SYNTAX Trial. On September 11, 2011, we are pleased to announce that with co-sponsorship with SCAI, we will be offering a transradial interventional training program with several worldwide leaders in this technology, including Mehrdad Saririan, Ian Gilchrist and Tift Mann. For further information, please contact lsteigerwald@promedicacme.com.

References

1. Claessen BE, van der Schaaf RJ, Verouden NJ, et al. Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention. J Am Coll Cardiol Intv 2009 Nov;2(11):1128–1134.
2. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): A randomised, parallel group, multicentre trial. Lancet 2011 Apr 23;377(9775):1409–1420. Epub 2011 Apr 4.

Figures:

Figure 1. The RCA angiogram reveals a tight stenosis in the mid RCA.

Figure 2. The RAO left angiogram reveals the chronic circumflex occlusion.

Figure 3. The RCA angiogram post stenting.

Figure 4. The RCA angiogram in the AP projection.

Figure 5. The left coronary angiogram reveals a tight LAD stenosis.

Figure 6. The left coronary angiogram after stenting of the LAD.

Figure 7. The left coronary angiogram in the LAO projection revealing the 100% circumflex occlusion.

Figure 8. The circumflex CTO is crossed.

Figure 9. The RAO angiogram after crossing and stenting of the circumflex CTO.

Figure 10. The RAO angiogram of the successfully treated circumflex CTO after NTG infusion

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Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at The Johns Hopkins Hospital in Baltimore, Maryland.