TRANS-RADIAL PRIMARY PCIIN A PATIENT WITH 3-VESSEL CAD

PRESENTED WITH ACUTE INFERIOR STEMI AND CARDIOGENIC SHOCK

Bambang Budiono, MDHeart & Vascular Center

Awal Bros Makassar HospitalIndonesia

Primary PCI : Trans-femoral vs Trans-radial

Transradial Primary PCI :

Less access Bleeding Complication

(up to 80% reduction)

does not prolong door-to-ballon time,

And improve clinical outcome

Bleeding Complications

Advances in antiplatelet and anticoagulant therapies in patients with ACS undergoing PCI potentially increase bleeding complications.

Bleeding associated with increase risk of mortality, recurrent MI and strokeTherefore, Transradial PCI is

a default strategy in ACS

TR-Primary PCI : The limitations

Limited guide catheter size (could be solved with sheathless GC)

Not palpable Radial artery

Renal failure on haemodyalisis

In patients with Cardiogenic shock (need IABP insertion)

Transradial primary PCI is even acceptable in

Cardiogenic shock, when the use of both IABP and ECMO,

is needed Simultaneously

Clinical History:

A 55 Y.O male, was referred from other private hospitalpresented with typical angina > 1 hour, diaphoresis, bradycardia, and hypotension(BP: 75/50 mmHg, HR : 45 bpm), unconsious.

PMH : SAP (CCS 2) since > 1 year & positive TMT, not keen to undergo coronary angiography

Traditional risk factors : Heavy smoker, DM Type II

Laboratorium result : Hb : 13 g/dl, Platelet : 292 .103/ulCreatinin : 0.9 mg/dlRandom Blood Sugar : 225 mg/dlLDL : 66 mg/dl, HDL: 35 mg/dl

ECG : ST elevation : II, III, aVF (no ST elevation at V3R, V4R)

The Strategy

GP2b/3a inhibitor (Integrillin)Vasopressor + Inotropic

IABP ?Temporary Pace Maker ?

Primary PCI: Transfemoral !

Dobutamin 5 ug/ kg bw/mntNorepinefrine 0.05Ug/ kg bw/mnt

BP : 75/50 mmHg HR : 46 bpm

BP : 105/60 mmHg HR : 75 bpm

Watchful waiting forIABP insertion

CoronaryAngiogram

RAO – Caudal View

LAO – Cranial View

LAO – Cranial View

Trombus aspiration using a 6 Fr Thrombuster

Trans-Radial primary PCI

GC : 6 Fr TR4, GW : Pilot 50

1st - Stage

First Stage

GC : a 6 Fr TR4GW : Pilot 50 0.14”

XIence Prime Stent : 3.0x23 mm

After Thrombo-aspiration Direct Stenting

Final Result

Door to Timi-3 Flow time : 35 minute

Procedure Time : 20 minute

Contrast Volume : 60 CC ( Dx & PCI)

After PCI

Before PCI

ECG : BEFORE AND AFTER PCI

Points to discuss with the patient

A diabetic Patient with small and long lesion in LADEcho : LVEF : 63 %SYNTAX SCORE : 29.5EURO SCORE : 2 ( Mortality : 1.51%)

Options :

1. Off/ on Pump CABG : LIMA to LAD – RIMA/ left radial to OM2. Hybrid procedure : LIMA to LAD , DES/BVS to prox.

3. Second stage PCI to LCX and LAD (DES or BVS) √

PTCA ke II

3-DAY AFTER2nd-Stage PCI

LCX- 1st attempt

GC : a 6 fr BL 3.5

GW : a 0.014” Runthrough NS hypercoatDirect Stenting : Xience Prime 3.0x12 mm ( 14 atm)

3-DAY AFTER 2nd-Stage PCI

LAD-2nd attempt

Mid LAD totally occluded

0.014” Runthrough Hypercoat GW (SB)

0.014” Pilot 150 GW, crossing CTO

Predilatation : Minitrek 1.5x12 mm

Minitrek 2.0x15 mm

Replace GW : Pilot 150 with

Runtrhough NS HC 0.014”

Stent : Xience Prime 2.5x38 mm

Stent Xience Prime 2.5x18mm After Post Dilatation : NC 2.5x15 mm

Final Result

Summary :

Trans-radial primary PCI was successfully done in a patient with 3 vessel CAD presented with Acute inferior STEMI complicated with Cardiogenic shock who well respond with vasopressor and inotropic drugs. Lesions in the LAD and LCX was staged 3-day afterward.

The patient was discharged on 5th day without any symptom. Laboratory result showed no renal impairment despite episode of cardiogenic shock before PCI.

Conclusion

Performing trans-radial primary PCI in STEMI with CS withoutthe use of mechanical haemodynamic support is doable ingood responder (to vasopressor/ inotropic agent) patients.

Rapid reperfusion is the key of success to stabilize Haemodynamic in patients with CS caused by AMI

However, decision of choosing the access site for Primary PCI, should be based on careful clinical judgment,

and experience of cathlab Staffs and operators.