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Angioplasty is not suitable for Coronary Bypass surgery complicated with induced coronary perpetuation

Case Study | Angioplasty - VishwaRaj Hospital
Case Scenario
A 63 years old Female known case of HTN & DM was admitted with history of non-ST MI CAG showed TVD, with proximal LAD showing calcified 90%. Mid LAD long 95% stenosis. Nondominant circumflex proximally had 50% followed by 90% in small sized Om1. LVEF was 40%
What is Angioplasty?

An angioplasty is a procedure to open the blood vessels that supply blood to your heart muscle nonsurgically. These blood vessels are also known as coronary arteries. Doctors often perform this procedure immediately after a heart attack.

The procedure is also called a percutaneous transluminal coronary angioplasty or percutaneous coronary intervention. This involves inserting a stent in the artery. The stent helps keep the blood flowing and the artery from narrowing again.
Having an angioplasty within the first hours after a heart attack may reduce your risk of complications. Timing can be crucial. The faster you receive treatment for a heart attack, the lower the risk of heart failure other complications, and death.

Angioplasty can also relieve the symptoms of heart disease if you haven’t had a heart attack.

Patient Management through Angioplasty

Patient was advised CABG. She was taken for CABG. In the operation room it was found after opening the chest that the pericardium was adherent to myocardium and hence CABG was not feasible. The chest was closed. The patient was then shifted to Cardiac ICU. The patient continued to get repeated episodes of angina at rest and used to go into LVF requiring BIPAP support. She also used to get episodes of hemoptysis. After discussing with patients relatives it was decided to proceed with angioplasty of the LAD.
Bronchoscopy and CT chest done to rule out alveolar hemorrhage and causes of hemoptysis. CT was uggestive ofpulmonary edema no E/O pulmonary embolism.

Patient was taken up for angioplasty. Left main coronary artery was cannulated with 7F EBU guide. Lesion in LAD was crossed with Run Through wire. The lesion was predilated with 2.0X20 balloon & 3×12 balloon. The distal LAD was stented with 2.5X 40 mm stent. Proximal LAD was stented with 3X28 stent and overlapped the distal stent.

Post stent deployment in the stent segments were dilated with 2.5X15NC balloon and 3 X12 NC balloons. Check angio showed 95% to 0% stenosis with TIMI III flow. However distal LAD shaved a perforation induced by the wire at 2 sites. A 3X8 mm balloon was used to occlude the distal LAD. A 2nd wire was passed into the LAD. The balloon was then exchanged with a microcatheter and fat globules were used in an attempt to close the perforation. They could not close the perforation.

Bedside ECHO was done which showed no evidence of pericardial effusion. One LAD wire was then exchanged with a Contata micro catheter and embolization was performed using Hila micro coils. These coils occluded one perforation but second persisted. Next the Contata catheter was exchanged with a Prowler Select Plus catheter and Axium micro coils were deployed. Check angio showed distal perforation still persistent but flow had reduced. Repeat ECHO showed no evidence of pericardial effusion. The patient was stable hemodynamically.

Heparin was not reversed in view of proximal and mid LAD stent. It was decided to observe the patient. Relatives were explained.

Patient was shifted to ICU and femoral sheaths were removed after 4 hours. A repeat ECHO was done after every 4 hourly for 24 hours. Patient had no angina and remained hemodynamically stable post procedure. The patient was shifted to ICU after 48 hours. Patient was discharged 4 days after the procedure. During the stay patient had no angina and no further episodes of heart failure On follow up patient remains Angina free and has had no episodes of Pulmonary Oedema LV Failure.

About Surgeon –
Dr Prasad Shah
D.M. in Cardiology from G. B Pant Hospital (Delhi University, India), DNB in Cardiology from KEM, Mumbai, Clinical Fellowship in Interventional Cardiology, (University of Toronto, Canada), Clinical Fellowship in Electrophysiology and Pacing (University of Toronto, Canada), M.D. in General Medicine (Mangalore University, India) with GOLD Medal.
Our Cardiologist Team –
Our Anesthesia Team –

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    Department of Cardiology and Cardiothoracic Surgery
    We believe that taking care of your heart should be a priority, not an option or choice. Our team of renowned cardiologists, state-of-the-art technology, and excellent support staff work together with a “patient-centric” philosophy, ensuring you always receive the best treatment.
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