VULNERABLE PLAQUES:VULNERABLE PLAQUES: Pertinent dPertinent doubts and solutions in oubts and solutions in

interventional cardiologyinterventional cardiology

EuroPCREuroPCR

Paris, 16 May 2006Paris, 16 May 2006

Case 1

• ♂ 62 year-old• CV risk factors: Diabetes mellitus type 2

Hypercholesterolemia

• Previous history: NQWMI (1990) > Stenting of prox-RCA NQWMI (2005) > Stenting of prox-LAD

• Actual symptoms:after an orthopedic operation to the right knee (april 2006), 2 episodes of unstable angina at rest lasting 15’each, with pain referred as the same of the previous NQWMIs without ECG changes but minimal troponine increase

• Strategy: Coronary angiogram was planned

Case 1

• Coronary angiogram:

-RCA:Good result of the stent in the proximal part.No further severe stenoses.

-LCA:Good result of the stent in the proximal part.90% stenosis of ostial D1 (covered by the stent in LAD) with TIMI 3 flow, same as just after stenting.No further severe stenoses.

Case 1

• After Ventriculography (normal LV function with mild inferior hypokinesia):

-New onset retrosternal pain, referred as the same as the 2 previous episodes of unstable angina.

• New control coronary angiogram:

-RCA: same as before.-LCA:…

Pre

Post

After 5’ less pain but…

IVUS of LAD

Thrombus in mid-LAD

Non “flow-limiting” thrombus, just atthe ostium of a small septal branch, superimposed on an eccentric plaquein the anterior descendens artery

plaque

thrombus

What to do?Pain started increasing again > We decided to stent the lesion

The patient could not receive aggressive antithrombotictherapy because of knee hemoarthros after recent surgery.No Abciximab was given, only aspirin and clopidogrel.

In hospital follow up

- Residual pain (not improved after stenting) for 3 hours (total occlusion of the small septal branch after stenting)

- Increase in post-procedural myocardial enzymes (18 h):

- CK: 124 U/l (normal: 57-374 U/l)- CK-MB: 21 U/l (normal <16 U/l)- Troponine I: 4.78 ng/ml (normal < 0.08 ng/ml)

Baseline

ThrombusSeptalbranch

Afterstenting

Case 2

• ♂ 51 year-old• CV risk factors: Arterial hypertension

• No previous cardiac hystory

• Actual symptoms:March 2006:aborted sudden death with VF and out-of-

hosptial resuscitation, due to NQWMI

• Strategy: Stabilization of the neurological situationCoronary angiogram planned 15 days after the acute event

Case 2

• Coronary angiogram:

-RCA:Non-dominant small vessel without evidence of severe stenoses.

-LCA:…

IVUS of mid-LAD

Ulcus

Virtual Hystology

Non “flow-limiting” ulcerated plaque

Predominantly fibrous plaque (stable?)

What to do?

Due to the “stable” clinical situation (no cardiac symptoms for 15 days), the “non-flow-limiting” appearance of the lesion at angiography and IVUS, and the “stable” nature of the residual plaque…

We treated the patient in a conservative way (aspirin, clopidogrel, statins, B-blockers)

Discussion

• Non flow-limiting lesions:

- “evolving” situation: thrombus formation superimposed on a potentially thrombus-prone “active” plaque

Versus

- “stable” situation: an ulcus in which the vulnerable part of the plaque (the necrotic core) has already disappeared

Discussion

• Role of the concomitant pharmacological therapy:

- is an aggressive antithrombotic therapy enough to limit thrombus formation and to avoid a complete occlusion of a major epicardial vessel?- what happens if the patient has contraindications to this type of aggressive therapy?

• Role of the percutaneous treatment of the lesion:

- is stenting justifed, exposing the patient to the risk of restenosis and stent thrombosis?

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