CASE PRESENTATIONCASE PRESENTATION

ByDr. Khalid Iqbal BhattiPost Fellow

SequenceSequence

Introduction Clinical History Clinical Examination Labs Images Discussion Follow-up

Clinical HistoryClinical History

52 Years Known case of diabetes mellitus for 14

years Know case of hypertension for 1 year Non smoker Non Asthmatic No previous History of IHD

Clinical HistoryClinical History contd…contd…

Chest pain/heaviness for 3 to 4 hours radiating both arms relieved by nitrates

During admission pain recurred Associated with sweating

Clinical ExaminationClinical Examination Pulse 72 beats/min BP 110 / 70 mmHg RR 22 breaths/min CVS Unremarkable ECG ST depression in V2 – V5

LabsLabs

Troponin less than 0.05 ng/ml Routine investigations Normal

SummarySummary

52 yrs present with USA having multiple risk factors and ECG changes

Recommended for Coronary cath

ImagesImages

Coronary Angiography

DiscussionDiscussion

Plaque shiftPlaque shiftThe lateral dislocation of plaque during dilatation therapy, which if directed towards a side branch, may occlude the ostium

Snow-plow injury Snow-plow injury a form of plaque shift that occurs at the carina of the bifurcation where plaque is dislocated from the parent vessel into the ostium of the side branch

Predictors  of  side  branch  Predictors  of  side  branch  occlusionocclusion Several mechanisms are

responsible for SB compromising during bifurcation treatment:1. Plaque shift “snow plow effect ”2. Dissection of SB after

balloon/stent in MB3. Spasm of SB4. SB ostium jailing by stent struts5. Carina stent-induced displacement

Characteristics of bifurcation Characteristics of bifurcation lesions PCIlesions PCI

Identification of Side Branch at riskIdentification of Side Branch at risk

Identification of Side Branch at riskIdentification of Side Branch at risk

SB Occlusion during PCI

Plaque Shift At Bifurcation Plaque Shift At Bifurcation LesionsLesions PCI of Bifurcation lesion is

challenging Side-branch compromise in 9-67%

of cases Protection of side branches is time

consuming, associated with more contrast media, radiation, and increased risk of complications as dissection, perforation, CIN

In bifurcation lesions in which there is no significant involvement of the side branch, we cannot predict the fate of the side-branch after PCI

Plaque Shift At Bifurcation Plaque Shift At Bifurcation LesionsLesions Intra-coronary near-infrared

spectroscopy can identify lipid-core plaques using the Lipiscan (InfraRedx) system

Lipid-core plaques are soft, and prone to plaque shift during PCI

Side-branch compromise as a result of plaque shift is associated with increased rate of peri-procedural MI and other complications

Near-infrared spectroscopy can potentially help to identify bifurcation lesions that are in increased risk of side-branch compromise

Both plaque shift from the MB and carina shift contribute to the creation / aggravation of a SB ostial lesion after MB stent implantation.

The mechanism of side branch(SB) luminal narrowing after main branch(MB) stent implantation in coronary bifurcation lesions is not completely understood.

Management / ProtectionManagement / Protection

Accurate stent positioning Protect side-branch with wire Nitrates to exclude spasm Kissing PTCA to side-branch Stent occasionally required IVUS

Follow-UpFollow-Up

Clinically ◦ No symptoms◦ No serial ECG changes◦ Vitally stable ◦ Observe for 24 hours◦ Glycoprotein IIb / IIIa inhibitor

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