Date post: | 07-Jul-2015 |
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Health & Medicine |
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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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THANKSTHANKS