Percutaneous coronary intervention of...
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Percutaneous coronary intervention of RIMA
The real challenge!
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Speaker's name:
I do not have any potential conflict of interest
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Clinical Case
76-year old
woman
Diabetes
Dislipidemia
Hypertension
Renal Insufficiency
NSTEMI 08.2013
Previous History
- Echocardiogram: Good left
systolic global ventricular
function – 55%.
- An immediate invasive
strategy was performed due to
recurrent chest pain > Severe
coronary disease: 3 vessels
disease including left main
disease.
- She was stabilized with intra-
aortic balloon pump until
CABG.
CABG:
- RIMA to left anterior
descending artery (LAD); LIMA
to obtuse marginal.
- No intercurrences after
surgery.
Hospital readmission 11.2013
Due to Post – CABG Angina.
Actual Disease
Coronariography:
- Left main stem 90% stenosis;
- Proximal left anterior descending
artery (LAD) 90% stenosis;
- First obtuse marginal (OM1) 50%
stenosis;
- Anastomosis of RIMA to LAD with
70% stenosis;
- Anastomosis of LIMA to OM1
with 50-70% stenosis;
- Distal right coronary artery with
suboclusive lesion.
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Coronariography
RAO 44º Cranial 27º
A
Description:
Figure A - severe left main stem
disease;
Figure B – Left anterior descending
artery with severe proximal disease;
Figure C – Anastomosis of LIMA to
obtuse marginal with 50-70%
stenosis;
Figure D – Right coronary artery
with suboclusive distal disease.
A B
LAO 2º Caudal 30º RAO 17º Cranial 30º
C D
LAO 8º Cranial 23º LAO 34º Cranial 0º
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RAO 44º Cranial 27º
H
RAO 30º Cranial 30º
G
LAO 8º Caudal 8º
F
RAO 37º Cranial 27º
E Description:
Figure E – Diagnosis catheter
documenting severe disease on the
anastomosis of RIMA to LAD.
- Selective catheterization of RIMA with
PCI catheter was unsuccessful due to
subclavian artery tortuosity, either by
radial or femoral access, despite all the
catheters used (LCB 6F; AR1 6F;EBU
6F; JL 3 6F; IM 6F; MPA 1 6F). Figures
E and F - radial access; G and H
femoral access.
It was decided to optimize medical
treatment and maintain clinical
surveillance.
She was discharged asymptomatic
with optimized medical treatment.
Coronariography
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Technique used to allow RIMA selective
catherization of
Description:
Figure I - Severe subclavian tortuosity (radial access). Figure J - It was performed a double access – femoral and radial with a stiff
wire in the catether of the femoral access. Figure H - Stretching the subclavian, allowed selective catheterization of the ostium of
RIMA with IM 6F catheter, through braquial access
I
RAO 28º Cranial 30º
I J K
New hospital admission 12.2013 due to Unstable AnginaIt was tempted again PCI of the
anastomosis on the RIMA.
LAO 0º Caudal 0º
I
RAO 28º Cranial 30º
J K
RAO 28º Cranial 30º
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PCI of the RIMA anastomosis lesion
Description:
Figure L – RIMA treated with balloon angioplasty.
Figure J – Good final result of PCI.
I JM
RAO 45º Cranial 20º
L
RAO 28º Cranial 30º
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Inferior and lateral necrosis. Mild ischemia in basal portion of
anterior wall.
Myocardial perfusion
scintigraphy (08-2014)
Left systolic dysfunction (EF 45%), akinesia in mid and basal
segments of inferior wall and hypokinesia in mid and basal
segments of posterior and lateral walls. Mild mitral
insufficiency.
Transthoracic
echocardiography
(10-2014)
Our patient was under optimized medical treatment, in class II of NYHA , with stable angor - CCS
I/II until December 2014, when she was again readmitted with unstable angina.
Follow-up
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Angiographic follow-up
Description:Figures N and O - Persistence of good result of previous PCI on the anastomosis of RIMA to LAD. Figure P -
Lesion of 70-80% on the anastomosis of LIMA to obtuse marginal, treated with balloon angioplasty.
After that, our patient is in class II of NYHA, with stable angor - CCS I/II, without new hospital admissions.
O
LAO 4º Cranial 13º
N
RAO 17º Caudal 15º RAO 7º Craudal 2 º
P
Double artery access can be useful to allow catheterization of IMA artery in difficult anatomy.
Conclusion