Posts Tagged ‘priamry pci’

Modern  day cardiac scientists have legally defined a significant coronary  lesion as > 70 % obstruction. Unfortunately this rule is applicable more in  academic forums not in cath labs.

While the guidelines seem to be clear in chronic coronary syndromes , in ACS  the interventional strategies based on  severity of lesion is  not  clearly defined.

Many times  in a  recannalised coronary artery following STEMI  (Either  spontaneous  or pharmacological )  even a 10-20  % lesion is stented .(Mind you ,  coronary erosion  that  trigger  pure thrombotic  STEMI  will be stented by most  of the  proud  young cardiologists of today !) The guidelines conveniently  ignore this area  allowing  the cardiac physicians  to  indulge in the coronary exotica !

Is this logical ?

Why do you need to stent a successfully lysed coronary  lesion with TIMI 3 flow. ?(We do know , many  young infarcts have pure thrombotic STEMI with zero % lesion   (In India 40% of young STEMI has near normal CAG  )

This situation arises by an ill conceived concept called pharmaco- invasive approach where routine coronary angiogram is advocated even after successful thrombolysis  in patient  who is asymptomatic and complete salvage of myocardium has been achieved  by pharmacological means .

* The only way to prevent this excess  is to ban the  pharmaco -Invasive approach for  asymptomatic and apparently successful thrombolysis .(Better still  even CAG should be banned ! for  the  simple reason an inappropriate CAG  begets an Inappropriate PCI !)

A Narrow  gap  separates  Ignorance and  knowledge !

Does the  PCI  makes the  ill-fated site  less vulnerable   for future events  . . .  when compared to   well  re-cannlised native coronary artery with negligible lesion ?

The funny side of  cardiac science  can be appreciated , when  somebody  is implanting a latest generation stent for 10-20 % lesion  just because it is associated with an ACS ,  another would astutely   study  the significance of 70-80% lesion  by FFR  in  an adjacent lab !



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Soft skills in pPCI 

Experience  would tell  us only about 70-80 % of STEMI are truly eligible for a  good  quality pPCI .(Multivessel CAD, Complex bifurcation lesion, difficulty in identifying IRA, No IRA-sapsms , complete spontaneous reperfusion )  The remaining 20-30 %  should , logically  be included in the failed pPCI category .This fact is largely concealed in the literature .

Beware of huge thrombus load in every patient with STEMI .The  contribution of  mechanical occlusion  vs thrombus  (in the total occlusion )  is the single most important factor in determining the intervention strategy.

Deploying a stent in a poorly  prepared (debrided of thrombus  ) lesion confers  further continuous  risk of a STEMI .Stents smartly jail  even large thrombus against the coronary vessels and they release it into the lumen in a controlled fashion  and prolong  the  acute coronary  risk phases

If thrombus aspiration  does a neat job and establishes a good   flow , if the   lumen  appear   good , think twice or even thrice before deploying a stent .It is akin to stent a  zero % lesion and we know it is foolish to do that at any stretch of imagination .(Stenting has never been proven to convert a vulnerable ulcerated lesion into stable one )

IVUS, OCT are not the answer in the above situations  as we are dealing with  emergency coronary  fire fighting !

Of course the intensive anti-platelet   protocols , will take care of  potential after effects of the intra coronary contact sport we play  !    . But . . . there is a limit for every thing. So spend as little time as possible when attempting catheter based reperfusion during STEMI.

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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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