1. By Deepak Natarajan

    Monday, June 30, 2008

    Operator(s):

    Deepak Natarajan(MD, DM) and Vivek Prakash(DM)

    Affiliation:

    Indraprastha Apollo Hospitals,New Delhi

    Facility:

    Departments of Cardiology, Indraprastha Apollo Hospitals, New Delhi, India

    History:

    A 69 yr old non diabetic male who had already received one bare metal stent each in his proximal LAD and mid RCA 4 years ago was readmitted for severe typical chest pain at rest, with ischemic ECG changes and positive troponin I values. On examination his heart rate was 60/min, blood pressure 180/110 mm Hg and he had a loud first sound with clearly audible S4. There was no evidence of heart failure.

    Angiography:

    His coronary angiogram revealed

    Left main : normal.
    LAD : Patent stent and rest of the vessel normal (Figure 1).
    Left Cx ; Patent stent with non critical proximal lesion of 30%.
    RCA ; Patent stent with 75 %to 90% stenosis involving the RCA/PDA bifurcation (Figure 2).
    LV angiogram : Normal size LV with good LVEF of 60%.

    Procedure:

    The right coronary artery was engaged with a 7Fr JR guiding catheter and a floppy wire 0.014 was introduced across the lesion into the PDA. Following predilatation by a 2.0/15 mm balloon a 2.5/20 PES was deployed at 18 atm (Figure 3). Angiograms demonstrated no residual stenosis in the stent but a 90% ostial stenosis in the Postero-lateral branch secondary to the stent (Figure 4). A new hydrophilic wire was negotiated across the stent into the large PLV branch and the struts dilated with an 1.5/10 mm balloon. A 2.0/10 PES positioned with its proximal end 2mm within the MV for an internal crush (Figure 5). Following deployment of the SB stent at 16 atm and a repeat angio the SB stent was next crushed with a 2.5+20 balloon at 20 atm (Figure 6 and Figure 7). The side branch stent struts were expanded by a 2+10 mm balloon at 16 atm (Figure 8) and eventually kissing balloon angioplasty was employed to achieve excellent results (Figure 9).

    Conclusion:

    There was no residual stenoses or dissection (Figure 10 and Figure 11). The procedure was preceded by 2 bolus injections of eptifibatide. He was discharged after 2 uneventful days in the hospital on aspirin,clopidogrel,cilostazol and fondaparinux.

    Comments:

    Management of bifurcation lesions continue to evolve rapidly with the provisional stenting approach considered to be the best. As the PLV branch had no lesion this was a classic case for provisional stenting of the side branch. The internal crush should prove to be the easiest,safest and most logical approach in such lesions.

    Conflict of Interest:

    None

  2. By Deepak Natarajan

    Monday, December 03, 2007, www.tctmd.com

    Operator(s):

    Deepak Natarajan MD, DM
    Amit Malik MD, DM

    Affiliation:

    Indraprastha Apollo Hospitals,New Delhi

    Facility:

    Departments of Cardiology
    Indraprastha Apollo Hospitals, New Delhi, India

    History:

    A 72 year old obese female with long standing hypertension was urgently referred to the cardiac catheterization laboratory for repeated episodes of severe central chest pain accompanied by shortness of breath and perspiration at rest for the past 10 days. She had a family history of coronary artery disease, but did not have diabetes mellitus. Her electrocardiogram revealed marked ST segment depression in almost all leads.

    Angiography:

    • 80% distal left main (LM), 80% ostial left anterior descending (LAD) artery, and 90% ostial left circumflex (LCX) artery stenoses (Figure 1Figure 2 & Figure 3). The LM was a large 4.5 mm vessel.
    • The right coronary artery was also critically blocked (Figure 4).
    • The left ventricular angiogram showed a normal sized ventricle with good contractions and ejection fraction of 56%.

    Procedure:

    The patient and her attendants consented to percutaneous intervention rather than CABG after being informed in detail of the pros and cons of both procedures. An intra aortic balloon pump was kept on stand by in the lab, and a temporary pacing lead was positioned in the right ventricular apex. The left coronary artery was engaged with a 7Fr JL 3.5 guiding catheter, and two 0.0014″ floppy guidewires were placed across the lesions in the LAD and LCX arteries. Both lesions were predilated by a 2.25x15mm balloon sequentially (Figure 5Figure 6) with the balloon placed across the LM. Next two 3mm Paclitaxel-eluting stents were advanced one by one into the LAD (3×23 mm) and the LCX (3×15 mm) arteries; and both stents were pulled back into the LM artery in order to completely cover the LM lesion (Figure 7). After confirming the position of both stents, they were deployed with simultaneous inflations at 16atm (Figure 8). This was followed by sequential dilations of the LAD and LCX stents at 18atm (Figure 9 & Figure 10). Next kissing balloon was done by simultaneous dilation of 2 balloons at 12atm. (Figure 11). The patient had been preloaded with aspirin plus clopidogrel and received standard bolus dose of Eptifibatide before the procedure along with unfractionated heparin, and the intervention was followed by 24 hour Eptifibatide infusion.

    Conclusion:

    There was TIMI 3 flow and no residual stenosis or dissection in any vessel (Figure 12Figure 13 & Figure 14). There were no complications. The entire procedure was over within 20 minutes.

    Comments:

    Drug eluting stents (DES), in conjunction with advances in peri and post procedural pharmacotherapies, have demonstrated the feasibility and efficacy of percutaneous intervention in unprotected left main coronary artery stenosis. In the recently concluded TCT 2007, the LE MANS randomized study comparing PTCA and stenting with CABG in unprotected left main stenosis demonstrated that stenting is not only safe and feasible for treatment of left main artery disease, but may also achieve better functional outcome than CABG. The 52 patients randomized to stenting had significant increase in left ventricle ejection fraction, and there was no difference in mortality or target vessel revascularization between the two treatment cohorts. More than a half (58%) of the patients had distal left main disease in the stenting group. A multicenter registry has recently recorded that percutaneous coronary intervention with DES in non bifurcation left main coronary artery disease appears safe with a restenosis rate of 0.9 %, long term major adverse clinical event rate of 7.4%, and a cumulative cardiac mortality of 2.7% at a median follow-up of 886 days. Bifurcation left main stenting, however, remains a challenge; but better stent platforms, novel procedural techniques, and optimal pharmacotherapies will further improve outcomes. Large randomized trials comparing DES to CABG such as the Synergy Between Percutaneous Intervention with TAXUS and Cardiac Surgery (SYNTAX) will provide answers to the uncertainties that remain with LM stenting. In this particular case the large left main artery necessitated the Simultaneous Kissing Stent technique as opposed to the Pull Back T Stenting method.

    Conflict of Interest:

    None

  3. By Deepak Natarajan

    Monday, July 23, 2007, www.tctmd.com

    Operator(s):

    Deepak Natarajan MD, DM

    Affiliation:

    Indraprastha Apollo Hospitals,New Delhi

    Facility:

    Departments of Cardiology
    Indraprastha Apollo Hospitals, New Delhi, India

    History:

    A 58 year old male presented with non ST elevation myocardial infarction. He was a heavy smoker, but was not hypertensive or diabetic. The 12 lead EKG revealed ST-segment depression in the precordial leads and Troponin-T was positive. The previous day he had experienced near collapse accompanied by sternal chest pain and perspiration.

    Angiography:

    • 75%-80% proximal LAD stenosis (Figure 1).
    • 70% proximal LCX stenosis (Figure 2).
    • 90% stenosis of the mid RCA adjacent to the origin of a large right ventricle branch (Figure 3).

    Procedure:

    The left coronary artery was engaged with a 6Fr JL guiding catheter, and a 0.0014″ floppy guidewire negotiated across the LAD stenosis that was predilated with a 2.0x15mm balloon (Figure 4); and an everolimus-eluting stent (Xience) 3.0x18mm was deployed at 18atm (Figure 5). There was no residual stenosis and TIMI 3 flow was achieved (Figure 6). The same guidewire was then positioned in the LCX and the lesion stented with a bare metal ( Vision) stent 3.0x15mm at 18atm (Figure 7). Angiography showed excellent flow into the LCX without any dissection (Figure 8). The RCA was next engaged with a 6Fr JR guiding catheter. Two floppy 0.0014″ guidewires were negotiated into the distal RCA and the right ventricle branch (Figure 9). The RCA stenosis was predilated with a 2.0x15mm balloon; and a 2.5x18mm bare metal stent (BMS, Vision) was positioned across the lesion. Before inflating the stent, the guidewire in the right ventricle branch was removed (Figure 10); and the BMS deployed at 19atm (Figure 11). The final angiogram did not show any significant residual stenoses or dissection of either the main RCA or right ventricle branch (Figure 12).

    Conclusion:

    It was possible to achieve excellent flow in all 3 major vessels without any complications. The side branch of the RCA was not compromised. The patient was discharged the next day.

    Comments:

    The ARTS 11 and ERACI 111 studies comparing multivessel stenting involving DES with CABG have demonstrated comparable MACCE at follow up as for long as 3 years. The ARTS 11 trial used an average of 3.7 drug eluting stents with an average length of 73mm. The present case is an illustration of multivessel stenting utilizing one DES and 2 bare metal stents. the results were quite reasonable and there were no complications. Moreover, the tight bifurcation stenosis of the RCA could be managed with a single stent in the main vessel. The side branch was a little over 2mm; therefore, provisional stenting was never on the agenda, but in the event of significant residual stenosis or dissection of the side branch balloon angioplasty would have been possible. The SYNTAX and other ongoing randomized trials comparing multivessel stenting in 3 vessel disease with CABG should shed further light on multivessel stenting.

    Conflict of Interest:

    None

  4. By Deepak Natarajan

    Monday, February 26, 2007, www.tctmd.com

    Operator(s):

    Deepak Natarajan MD, DM

    Affiliation:

    Indraprastha Apollo Hospitals,New Delhi

    Facility:

    Departments of Cardiology
    Indraprastha Apollo Hospitals, New Delhi, India

    History:

    A 66 year old hypertensive lady had undergone stenting of her mid right coronary artery (RCA) in 2001. She was on eltroxin for hypothyroidism and was admitted in the ER this time for chest pain at rest and on exertion for the preceding 2 weeks.

    Angiography:

    • Normal left anterior descending artery (LAD) (Figure 1).
    • Normal right coronary artery (RCA) (Figure 2).
    • The left circumflex (LCX) artery was anomalous and was seen to be arising from the right coronary sinus very close to the origin of the RCA and had a tight 75% ostial stenosis (Figure 3).

    Procedure:

    The LCX was canalized with a 6Fr AR1 guiding catheter, and a 0.0014″ All Star guidewire was advanced across the LCX lesion (Figure 4). Direct stenting was done using a Multilink Vision bare metal stent 3x12mm at 16atm (Figure 5). The patient had been maintained on nitroglycerin infusion throughout the procedure and received a bolus of eptifibatide immediately before stenting.

    Conclusion:

    TIMI 3 flow was achieved and there was no residual stenosis (Figure 6).

    Comments:

    Coronary artery anatomic variations are uncommon and have been seen in approximately 0.6-1.6% of patients undergoing coronary angiography. The aberrant LCX from the RCA or the right coronary sinus is the most common anomaly observed and usually discovered by chance during coronary angiography or at autopsy. It is considered benign as it causes no myocardial compromise. However, it becomes important for the cardiac surgeon in case of aortic valve replacement. In the event of substantial atherosclerosis, the presentation may be as an acute myocardial infarction or unstable angina, as in this case. Percutaneous coronary intervention may be simple and effective in both instances.

    Conflict of Interest:

    None

  5. By Deepak Natarajan

    Monday, August 21, 2006, www.tctmd.com

    Operator(s):

    Deepak Natarajan MD, DM

    Affiliation:

    Indraprastha Apollo Hospitals,New Delhi

    Facility:

    Departments of Cardiology
    Indraprastha Apollo Hospitals, New Delhi, India

    History:

    A 59 year-old man was admitted to our service for unstable angina. He was a known hypertensive and had recently undergone an exercise ECG test which was strongly positive. He was not a diabetic and had stopped smoking a couple of years back. His LDL cholesterol was 150 mg%.

    Angiography:

    His coronary angiogram revealed a 95% bifurcation stenosis at the origin of the posterior descending artery (PDA) from a dominant circumflex coronary (LCX) artery (Figure 1). The left anterior descending artery (LAD) and the right coronary (RCA) arteries (non dominant) were normal (Figure 2).

    Procedure:

    The left coronary artery was engaged with a 7Fr Voda guiding catheter, and two 0.0014″ floppy guide wires were negotiated across the stenosis into the PDA and LCX arteries respectively. Following predilation with a 2x15mm balloon over both wires, a 3x18mm sirolimus eluting stent was positioned into the PDA while another 3x15mm sirolimus eluting stent was placed into the LCX artery. The PDA stent was placed slightly proximal to the LCX stent (Figure 3). The LCX stent was first deployed at 14atm; and following a coronary angiographic injection, the wire was removed. Next the PDA stent was deployed at 14atm. The result was satisfactory with no complications (Figure 4). The floppy wire was renegotiated across the PDA stent struts and a 3x15mm balloon was inflated upto 16atm. Subsequent to this, kissing balloon inflations were performed (Figure 5). The balloons were inflated upto 12atm. Angiography revealed a significant dissection of the PDA distal to the stent (Figure 6). This was then predilated with a 2.5x15mm balloon and stented with a 2.75x15mm bare metal stent which was deployed at 16atm (Figure 7).

    Conclusion:

    The final angiogram demonstrated TIMI 3 flow and no residual stenosis (Figure 8). The patient was discharged the next day.

    Comments:

    Dissection of a coronary artery may develop following crush technique stenting. Although uncommon, it can be managed with deployment of an appropriate sized stent. In this case a bare metal stent was used for the sake of economy.

    Conflict of Interest:

    None