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PCI after CABGPCI after CABGPCI after CABGPCI after CABG
WenWen‐‐Yi Yi GuoGuo, , HaichangHaichang Wang, Wang, WeijieWeijie Li, Li, YanhongYanhong FanFan
Department of Cardiology, Department of Cardiology, XijingXijing Hospital Hospital
,, gg g,g, jj ,, gg
Xi’an ChinaXi’an China
WenyiWenyi GuoGuo::WenyiWenyi GuoGuo: :
I do not have any potential I do not have any potential conflict of interestconflict of interest
HistoryHistoryHistoryHistory
•• malemale 7676 years oldyears old•• malemale,,7676 years oldyears old
•• ParoxysmalParoxysmal chest pain 1 monthchest pain 1 monthParoxysmalParoxysmal chest pain 1 monthchest pain 1 month
•• AMI and AMI and angioangio showed triple vessel showed triple vessel di d CABG d 8di d CABG d 8disease and CABG was done 8 years agodisease and CABG was done 8 years ago
•• Risk factors: Hypertension andRisk factors: Hypertension andRisk factors: Hypertension and Risk factors: Hypertension and hyperlipidemiahyperlipidemia
bl fbl f•• Diagnosis: unstable angina pectoris after Diagnosis: unstable angina pectoris after CABGCABG
ECGECGECGECG
OMI(anterior wall) and STOMI(anterior wall) and ST‐‐T depressionT depression( )( ) pp
Other dataOther dataOther dataOther data
•• CKCK‐‐MB and MB and cTnIcTnI: normal: normal
UCG OMI ( t i ll) EF 54%UCG OMI ( t i ll) EF 54%•• UCG: OMI (anterior wall) EF: 54%UCG: OMI (anterior wall) EF: 54%
•• LDLLDL C: 3 75C: 3 75 mmolmmol/L/L•• LDLLDL‐‐C: 3.75 C: 3.75 mmolmmol/L/L
•• Cr: normalCr: normalCr: normalCr: normal
Coronary angiographyCoronary angiographyCoronary angiographyCoronary angiographynative LCAnative LCA
Native RCANative RCANative RCANative RCA
Vein GraftVein GraftSVGSVG‐‐OMOM‐‐occludedoccluded
SVGSVG PDAPDA i l ii l iSVGSVG‐‐PDAPDA‐‐proximal narrowing proximal narrowing
LIMALIMA LADLAD patentpatentLIMALIMA‐‐ LAD LAD ‐‐ patentpatent
How to choose the therapyHow to choose the therapy
DrugDrug Cannot Cannot relieve relieve angina angina
RR CABGCABG Hi hHi h i ki kReRe‐‐CABGCABG High High riskrisk
PCIPCI Low risk and Low risk and feasiblefeasible
StrategyStrategyStrategyStrategyLCXLCX RCARCALCXLCX RCARCA
LMLM‐‐LCXLCX LCXLCX graftgraft Diffuse lesionDiffuse lesion Localized lesionLocalized lesionLMLM LCXLCX99% stenosis99% stenosis
LCXLCX graftgraftTotal occusionTotal occusion
Diffuse lesionDiffuse lesion Localized lesionLocalized lesion
LCX: more severeLCX: more severe RCA: simple lesionRCA: simple lesion
LCXLCX then RCAthen RCA
LMLM LCX PCILCX PCILMLM‐‐LCX PCILCX PCI
RR‐‐Radial Radial accessaccess
Guiding: 6F EBU 3.5Guiding: 6F EBU 3.5
G id i WG id i WGuide wire: BMWGuide wire: BMW
PP dil t tidil t tiPrePre‐‐dilatationdilatation
2 02 0××2020 balloonballoon2.02.0××2020 balloonballoon
St tiSt tiStentingStenting
2 752 75××2929 SSES d l d i OMES d l d i OM 3 03 0××2929 SES deployedSES deployed inin LMLM LCXLCX2.752.75××29 29 SSES deployed in OMES deployed in OM 3.03.0××2929 SES deployed SES deployed in in LMLM‐‐LCXLCX
Final resultsFinal resultsFinal resultsFinal results
ThenThenThen…Then…•• AsymtomaticAsymtomatic ‐‐Maybe no need to touch RCA?Maybe no need to touch RCA?AsymtomaticAsymtomatic Maybe no need to touch RCA?Maybe no need to touch RCA?
•• Went back home after 3 daysWent back home after 3 days
•• RT medical therapyRT medical therapy
•• ExertionalExertional angina after 18 monthsangina after 18 months
•• Administration and reAdministration and re‐‐angiograghyangiograghy
•• Everything isEverything is almost samealmost same with the resultwith the result•• Everything is Everything is almost same almost same with the result with the result after 1after 1stst stentingstenting
ECGECGECGECG
Then we decided to open SVGThen we decided to open SVG‐‐PDA of RCAPDA of RCAThen we decided to open SVGThen we decided to open SVG PDA of RCAPDA of RCA
RCA graft PCIRCA graft PCI
RR‐‐radial radial accessaccess
Guiding: 6F JR 4.0Guiding: 6F JR 4.0
Guide wire: Guide wire: RunthroughRunthroughGuide wire:Guide wire: RunthroughRunthrough
Spider filter (CV3)Spider filter (CV3)
B ll Dil t tiB ll Dil t tiBalloon DilatationBalloon Dilatation
2.52.5××15mm15mm balloonballoonDistal embolic protection Distal embolic protection pp
d d ld d lStentingStenting and post dilatationand post dilatation
4.04.0××20mm20mm DES DES deployed deployed ininThe The stent couldn’t fully stent couldn’t fully openedopened afterafter 30atm30atm NCNC00 00 SS dep oyeddep oyed
SVGSVG‐‐RCARCAopened opened after after 30atm30atm NC NC balloon dilatation…balloon dilatation…
Final resultFinal resultFinal resultFinal result
6 months later6 months later6 months later…6 months later…
•• Paroxysmal Paroxysmal dyspneadyspnea suddenlysuddenly
•• Administration after 7days (Transfer fromAdministration after 7days (Transfer fromAdministration after 7days (Transfer from Administration after 7days (Transfer from other hospital)other hospital)
•• TC: 8.10; TG: 2.95; LDLTC: 8.10; TG: 2.95; LDL‐‐C: 6.94C: 6.94
•• LDH: 311 IU/L; LDH1:118LDH: 311 IU/L; LDH1:118LDH: 311 IU/L; LDH1:118LDH: 311 IU/L; LDH1:118
•• CK and CKCK and CK‐‐MB and MB and TnTn‐‐I: normalI: normal
•• UCG: + inferior wall UCG: + inferior wall hypokinesiahypokinesia; ; EF: 36%EF: 36%
ECGECGECGECG
Native left and rightNative left and right
LIMA and LIMA and SVGSVG‐‐PDA?!PDA?!
Strategy of ReStrategy of Re‐‐PCIPCI
Native Native
Diffuse Diffuse lessionlession
OccusionOccusion time<18time<18 monthmonth
Native Native
Graft Graft
Totally occludedTotally occludedTotally occludedTotally occluded
Could not dilated fullyCould not dilated fully
Native RCA Native RCA PCIPCI
RR‐‐radialradial accessaccessRR‐‐radial radial accessaccess
Guiding: 6F JR 4.0Guiding: 6F JR 4.0
Wire: PILOT 50Wire: PILOT 50
MicroMicro‐‐chatheterchatheter: :
FinecrossFinecrossFinecrossFinecross
1 25 b ll ld ’t1 25 b ll ld ’t1.25mm balloon couldn’t cross…1.25mm balloon couldn’t cross…
PILOT 50PILOT 50 enter true enter true lumen lumen 1.25*15mm balloon dilatation1.25*15mm balloon dilatation×× b llb ll d ld lBalloon anchor techniqueBalloon anchor technique 1.51.5××20mm20mm balloon balloon dilatationdilatation
Af 2 0*20 b ll dil iAf 2 0*20 b ll dil iAfter 2.0*20mm balloon dilationAfter 2.0*20mm balloon dilation
StentingStentingStentingStenting
3.53.5××33mm SES33mm SES 3.53.5××29mm SES29mm SES
l ll lFinal resultsFinal results
F/u: Bad newsF/u: Bad newsF/u: Bad newsF/u: Bad news
•• PtsPts died of renal failure died of renal failure afterafter 1 yr1 yr
•• Heart was okay before dyingHeart was okay before dyingHeart was okay before dyingHeart was okay before dying
•• Cr: 87Cr: 87‐‐‐‐‐‐‐‐168168‐‐‐‐‐‐‐‐196196‐‐‐‐‐‐‐‐223223μμmol/Lmol/L
•• CystatinCystatin C: 2 4 mg/LC: 2 4 mg/LCystatinCystatin C: 2.4 mg/LC: 2.4 mg/L
•• ……
Take home messageTake home messageTake home messageTake home message
•• PCIPCI isis anan alternativealternative choicechoice toto revascularizationrevascularization•• PCIPCI isis anan alternativealternative choicechoice toto revascularizationrevascularizationofof ptspts afterafter CABGCABG
•• whichwhich vesselvessel shouldshould bebe revascularization,revascularization, nativenativeoror graft,graft, shouldshould bebe decideddecided byby manymany factorsfactors suchsuchasas operationaloperational feasibilityfeasibility succesesuccese raterate andand riskriskasas operationaloperational feasibility,feasibility, succesesuccese raterate andand risk,risk,etcetc
i li l b lib li ii d id i ii f lf l ii ii•• DistalDistal embolicembolic protectionprotection devicedevice isis usefuluseful inin veinveingraftgraft PCIPCI
•• OldOld ageage andand progressiveprogressive ofof renalrenal functionfunctionaffectedaffected thethe outcomeoutcome ofof complexcomplex ptpt
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