Multivessel PCI during acute STEMI is forbidden except in cardiogenic shock . (or in some very unstable patients without cardiogenic shock)
The reason
- During acute MI hemodynamics are precariously balanced.We do not know yet how emergency multivessel plasty alters this .
- Our initial aim should be confined to myocardial salvage in the IRA . Total myocardial revascularization is niether the priority nor its desirable.
- The more time you spend within the inflamed coronary artery , more its hazardous.
- Multiple stenting is prone for thrombus and migration into side branch .
- Stent opposition is sub optimal in many thrombus infested lesions.
Still . . . in real world it is extremely difficult to curtail the urge to stent all eligible lesion during primary PCI !
How to avoid it ?
If the patient is poor or the insurance limit is low , the issue of multi vessel stenting does not arise at all !
Always ignore complex non IRA lesions during primary PCI. Be happy if a non IRA has a bifurcation lesion !
Still , some lovely looking lesions in non IRA would be tempting and inviting . Indulge at your own risk !
* Please remember if the proximal LAD has a non IRA lesion , it may be sensible to attempt simultaneous revascularisation even if the patient is stable !
Other unrealistic advice
- Keep the professional fee and other benefits fixed whether we do a single or multiple vessel stenting (Realise . . . surgeons do not charge more for a 4 vessel by-pass graft than a single ! )
- Keep the current AHA/ACC/ESC guidelines pasted right next to the fluroscopy monitor .
- Ask your subordinates to repeatedly caution you about the possible excesses and ask them to wave a red flag !
- You may empower the senior staff nurse with a veto power to shut off the cath lab once IRA plasty is completed and the patient is stable.
- In extreme situations , keep a cath marshal ready to manually evacuate the primary operator from cath lab !
Reference
Dr.S.Venkatesan MD 