TCTAP 2012

A difficulty of the treatment for ACS

in a patient undergoing hemodialysis

Department of Cardiology Tokyo Medical UniversityDepartment of Cardiology Tokyo Medical University

Naotaka Murata Nobuhiro Tanaka Jun Yamashita

M hi O Y Ki K H hi Y h i H kMasashi Ogawa You Kimura Kou Hoshino Youhei Hokama

Akira Yamashina

I n t r o d u c t i o n

Recently, PCIs for patients undergoing hemodialysis are increasing.

Generally speaking there are many difficulties in a strategy of PCI for thoseGenerally speaking, there are many difficulties in a strategy of PCI for those

patients even in staged-PCI.

H f l PCI f i d iHere we report a successful emergency PCI for a patient undergoing

hymodialysis with ACS, which had specific problems, such as volume overload

by contrast agent, limited approach sites, tortuosity of iliac artery and sever

calcified lesion.

Case

A 79 year old man who had been treated to diabetes and undergone hemodialysisA 79-year-old man, who had been treated to diabetes and undergone hemodialysis

for 10 years, was received a staged-PCI for distal RCA (PES 3.5/24,2.75/20)

in March 2009.

His last CAG in September 2009 showed an intermediate stenosis inHis last CAG in September 2009 showed an intermediate stenosis in

proximal RCA. There were no significant restenosis in PES.

In June 2011,he admitted to our hospital on emergency because of acute heart failure.

Present Statue

Height 154cm, weight 56 kg, BMI 23.6

Consciousness clear

BP 182/95 mmHg, HR 110 bpm

℃RR 20 times/min orthopnea, BT 36.8℃

Heart Sound regular S3 (+) no murmur

Lung Sound wheeze (+)

Legs mild edema (+)

Skin wet and warm

Chest X-ray / ECG

Labo date

WBC 11200 /μl LDH 165 IU/l Na 140 mEq/l4RBC 311 104/ μl CPK 108 IU/l K 5.3 mEq/l

Hb 10.4 g/dl T-cho 133 mg/dl Cl 105 mEq/l4Plt 13.3 104/ μl LDL 77 mg/dl BNP 4340 pg/ml

Ht 32.1 % HDL 28 mg/dl NT pro-BNP

60000 pg/ml

TP 5.7 g/dl TG 103 mg/dl CRP 1.1 mg/dl

Alb 3.7 g/dl Glu 130 g/dl

AST 18 IU/l HbA1c 5.9 %

ALT 23 IU/l BUN 49.3 mg/dlγGTP 30 IU/l Cr 10.89 mg/dl

ALP 144 IU/l UA 5.9 mg/dl

Echocardiogram on admission

Hypokinesis in antero-septum (mid to apex)

Sever hypokinesis in Infero-posterior

EF 35%

Dd/Ds 47/32 mm, LA 42mm

IWS/PW 11/12 mmIWS/PW 11/12 mm

MR moderate

C A G - 1

RCA

C A G - 2

LCA

Clinical course

His acute heart failure was resolved after an intensive

management. Then, CAG was performed on 10 hospital days.

It revealed diffusely sever calcified lesions in 3VD .

So we developed a staged-PCI strategy using a Rotablator device for RCA,

which seemed to be the culprit lesion of this event.

However, he complained of chest pain with ST-T changes in ECG during

hemodialysis 1 hour after the CAG.

It was supposed to be worsening myocardial ischemia caused by loading

contrast agent. Therefore, we urgently performed PCI for RCA.

P C I - 1

Iliac arteries Initial

Right 8Fr femoral artery approach

Coil long sheath GC AL1.0 STCoil long sheath

P C I - 2

Rotablator bar 1.5→2.0mm

GC JR4 0SH G W; Rinato SION Rota Extra supportGC JR4.0SH G.W; Rinato, SION, Rota Extra support

PCI-3

POBA

B.C; Hiryu 2.25/15, Lacross Hp 3.5/15

P C I - 4

proximalIVUS

mid

distaldistal

PCI-6

Stent

TAXUS Liberte 3.5/28 3.0/20

PCI-7

Final

D i s c u s s i o n

Problems of PCI for HD patients…

① Complicated lesion （sever calcified, diffuse, multi-vessel etc ）② Limited approach site (a shunt for HD tortuous iliac artery ）② Limited approach site (a shunt for HD, tortuous iliac artery ）③ Volume over load caused by contrast agent

Conclus ion

We experienced a difficult treatment for a patient who undergoing hemodialysis with ACS developed after CAG.hemodialysis with ACS developed after CAG.

As PCIs for hemodialysis patients would become more popular , it might be f y p p p gso important to review a strategy of PCI for such a complicated lesions/patients