A 65 year old gentleman presented to us with severe substernal chest pain within an hour of gastric bypass surgery.Â The patientâ€™s risk factors include morbid obesity, hypertension, hyperlipidemia and positive family history of heart disease.Â The patient is 5â€™9â€ and 330 pounds.Â His EKG shows non specific ST and T wave changes.Â At the time of presentation, his enzymes were not back, and there are no acute changes on his electrocardiogram.Â His troponins were positive and this was treated as a non ST elevation myocardial infarction.
The first question is do you catheterize this gentleman who is nearly 200 pounds over his weight via the right groin or use the radial technique.Â His angiogram revealed him to have good
The answer is that we did treat the patient with his acute coronary syndrome via the right radial artery.Â AngiomaxÂ® (The Medicines Company, Parsippany, New Jersey) was started and the right coronary stenosis (which we felt was the ischemic producing lesion)Â was approached with an Akari 2.0 guide (Terumo, Somerset, New Jersey), and the FielderXT wire (Abbott Vascular, Abbott Laboratories, Illinois).Â When we placed a 3.0 x 12 EndeavorÂ® (Medtronic, Minneapolis, Minnesota) stent distally and a 3.0 x 30 proximally, the stenosis went from 70% proximally to 0% distally, 99% to 0%.Â The patient was treated with Prasugrel and recovered nicely.Â Twenty-four hours later, the patient presented with chest pain again with some elevated troponins but no EKG changes.Â This time we went through the left radial artery with a 2.0 Akari guide.Â We crossed the LAD stenosis and placed a 3.0 x 12mm EndeavorÂ® stent and the ramus was then treated with a 3.5 by 9mm EndeavorÂ®.Â The LAD diagonal was felt to be too small for intervention so we decided to not approach this or the circumflex CTO.
Since this procedure was done on March 29, 2011, the patient has been asymptomatic. However, (1) do you treat the chronic total occlusion of the circumflex, (2) if so, when do you treat it and (3) or should the patient undergo surgery?Â Answer:Â Again, the patient is still morbidly obese, and he is not diabetic.Â In terms of his likely success long term, he will have a higher chance of restenosis and reintervention with drug eluting stents then surgery, but less likely to have complications associated with bypass in a morbidly obese gentleman, i.e., infections, etcetera, so he underwent successful recanalization of his chronic total occlusion of the circumflex.Â This was done via the right radial artery two months after the original presentation.Â We used an Akari 2.0 guide and crossed the lesion with a Provia wire (Medtronic,
This patient raises several questions.Â (1) when a patient has an acute coronary syndrome and has a total occlusion of one of the vessels, what is his prognosis?Â From a recent study in the
Cases like this will be discussed at our meeting at the Wynn Encore Hotel in
 Bimmer E.P.M., Claessen, MD, et al.: Evaluation of the Effect of a Concurrent Chronic Total Occlusion on Long-Term Mortality and Left Ventricular Function in patients after Primary Percutaneous Coronary Intervention.
 Sanjit S Jolly, Salim Yusuf, John Cairns, Kari NiemelÃ¤, Denis Xavier, Petr Widimsky, Andrzej Budaj, Matti NiemelÃ¤, Vicent Valentin, Basil S Lewis, Alvaro Avezum, Philippe Gabriel Steg, Sunil V Rao, Peggy Gao, Rizwan Afzal, Campbell D Joyner, Susan Chrolavicius, Shamir R Mehta; Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. The Lancet published Online 04 April, 2011 DOI:10.1016/S0140-6736(11)60404-2.