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 

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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