Posts Tagged ‘infarct related artery’

How to manage multi -vessel CAD in STEMI ?

In this era of explosive information  , we rarely get clear-cut answers to  our  problems.

There are rare  exceptions . Here is an wonderful  review article on the issue of multi-vessel CAD  during STEMI. (http://www.ncbi.nlm.nih.gov/pmc/articles)   Especially  heartening ,   is the way the article concludes . It can not be more crisp than this !

Conclusion (Reproduced from the above article )

  •  Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI).
  • Acute multi-vessel PCI can be justified only in haemo-dynamically  unstable patients with multiple truly critical (90%) lesions.
  • Significant lesions of the non-culprit arteries should be treated either medically or by staged revascularization procedures— both options are currently acceptable.

In-spite of the clearest possible guidelines   there  are frequent   debates  going on  for aggressive approach  to non IRA  lesions in hemo-dynamically  stable patients  as well  !  Many of the  learned cardiologists are calling for a  a  “legal violation”  of above guidelines !

The term staged primary PCI (Non IRA)  is often misused  . One such strategy is  rescheduling the non IRA PCI by 24 to 48 hours  later  than  the primary  ira PCI.  This  enables  us to violate the guidelines silently   . Please mind , the excess morbidity of non IRA PCI is due to the altered hemo -rheology which is expected to persist for at least few weeks !

I have recently come across a  cardiologist performing RCA PCI on Monday and LAD PCI (A 70 % lesion )  on Wednesday in a hemo-dynamically stable inferior STEMI ( Incidentally , he  felt  no guilt  , as  he was   ignorant about  existence of such  guidelines . In fact ,  he wanted to finish both angioplasties  on the same sitting  . It seems  he had to defer  the LAD  PCI   to Wednesday as the initial insurance  limit was exceeded   .

I do not want to dwell into another  unfortunate story  , as  this   patient had  to borrow  Rs 1.25lakh for  his life saving second stent  !

Final message

Come on   . . . let us violate the primary PCI guidelines . . . after all , our patients do not know the reality !


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Primary PCI (pPCI) is probably*  the   best modality in the management of STEMI .

( *Probably because ,    we  know “Time” ( fate !) is  still the  most crucial determinate of ultimate outcome of STEMI )

Any experienced interventional  cardiologist will be aware of the surprises  and difficulties  they encounter during primary PCI.

The pPCI  is all about  opening up the IRA rapidly and  wheel  out  the patient  from cath lab at the earliest.

But ,  ironically , an often  under- reported   issue  is the difficulty in  identifying IRA itself  !

One may wonder  , how this can happen ?

Following difficulties  can occur  in identifying IRA during  primary PCI*

(* There are some  hyper-talented  cardiologists who would never consider IRA recognition as an issue  .This article is not meant for them.)

The problems can range anything between the following   queries

  • Where is the IRA?
  • Is that the IRA?
  • No IRA ?
  • Multiple IRAs !

Angiographic encounters during  pPCI  and  IRA  trouble shooting .

  • When there is diffuse multivessel disease.
  • Thrombus vs  eccentric plaque  both  showing  intra luminal filling defect .
  • Thrombus spill over to adjacent branch or A mid LAD lesion with  stagnating thrombus extending to LCX ostium  mimicking two IRA
  • A bifurcation lesion with both LAD and LCX  ostial occlusion.
  • Multiple active looking  plaques with thrombus
  • STEMI in patients with preexisting CAD . Is it a CTO ?  ATO ? (Acute total occlusion ) A  CTO  ,which is  fed by collaterals from contralateral artery  ,  if this feeding vessel is  occluded even  partially ,  STEMI will occur in CTO territory . Here  , for rapid salvage you need to open the vessel that feeds the CTO territory.
  • Post CABG and post PCI form a special subset . Some times it is very difficult or even impossible   to label a graft as an IRA

Finally and most importantly  , when  there is no visible lesion in any of the coronary arteries   and look  near normal  !   Is that  no IRA  ?  or Wrong diagnosis of STEMI ?  Every one blinks  in cath lab . The consultant  howls the fellow to verify the ECG . Finally it may  well turn out to be an early  repolarisation  syndrome . These are wages we  often pay for the modernity !

How to approach  the situation when one is confused with  identifying the IRA ?

The good old ECG will come to  our  rescue sometimes. Realise in a multivessel CAD  , ECG is also vested with errors.

Echocardiography  rarely  gives a convincing answer to localise IRA. (Segmental overlap , preserved sub epicardial  contraction , residual ischemia all tend to confound )

Most confusions occur between LAD and  diagonal /LCX as there can be a huge overlap in the ECG territory  anterolateral segments

In a infero posterior STEMI, if  you have both  RCA  / LCX lesion and you wonder which  is the IRA  it is easy to solve by looking for RV involvement. (LCX lesions however dominant they are  . 99/100 times can not infarct the RV significantly  !)

If the lesion  is in PDA  the  issue is made simple.

Doing a primary PCI  blindly without knowing the IRA

This is  modern-day cardiology  at its scientific  low ! . Cardiologists  indulge in such  things much more commonly than one would imagine.

Probably  they would reason ,  it is safe to stent every vessel that is potentiality  an  IRA  , rather than  missing it. Though the concept of  multivessel stenting in STEMI   may help   patients with complicated MI ,  like pump failure ,  it generally increases   risk of primary PCI outcome in otherwise stable STEMI. Primary PCI procedure must be as short as possible. The other option is to do plain balloon angioplasty in less deserving vessels.

Important considerations  in the setting of complex multivessel CAD  during pPCI .

  1. Fall back on medical therapy
  2. Staged PCI
  3. Deferred or Immediate CABG
  4. Hybrid procedures like PCI  with CABG

Final message

IRA identification can  indeed be a difficult task  during primary PCI.  Sound knowledge and experience about coronary anatomy and its draining territories especially  in  the setting  of  multivessel  CAD  is essential to avoid errors.

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