A Morbidly Obese Acute Coronary Syndrome Patient Presents with Three Vessel Coronary Disease: How Do You Treat?

A 65 year old gentleman presented to us with severe substernal chest pain within an hour of gastric bypass surgery.  The patient’s risk factors include morbid obesity, hypertension, hyperlipidemia and positive family history of heart disease.  The patient is 5’9” and 330 pounds.  His EKG shows non specific ST and T wave changes.  At the time of presentation, his enzymes were not back, and there are no acute changes on his electrocardiogram.  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.  His angiogram revealed him to have good LV function with mild inferior hypokinesis and an ejection fraction of 60%.  The right coronary had a 99% occlusion.  The left main was free of disease.  LAD had a high grade diagonal stenosis and a 70% LAD stenosis with a ramus with an 80% stenosis and the circumflex was occluded with right to left collaterals.  The patient had three vessel coronary disease.  He is not diabetic.  Would he best be treated with intervention or with bypass?  Secondly, what does it mean when a patient presents with an acute coronary syndrome and has a chronic conclusion of a non ischemic vessel.  Thirdly, if PCI is performed, do you do this all at one time or do you do this in a staged procedure? 

 

The answer is that we did treat the patient with his acute coronary syndrome via the right radial artery.  Angiomax® (The Medicines Company, Parsippany, New Jersey) was started and the right coronary stenosis (which we felt was the ischemic producing lesion)  was approached with an Akari 2.0 guide (Terumo, Somerset, New Jersey), and the FielderXT wire (Abbott Vascular, Abbott Laboratories, Illinois).  When we placed a 3.0 x 12 Endeavor® (Medtronic, Minneapolis, Minnesota) stent distally and a 3.0 x 30 proximally, the stenosis went from 70% proximally to 0% distally, 99% to 0%.  The patient was treated with Prasugrel and recovered nicely.  Twenty-four hours later, the patient presented with chest pain again with some elevated troponins but no EKG changes.  This time we went through the left radial artery with a 2.0 Akari guide.  We crossed the LAD stenosis and placed a 3.0 x 12mm Endeavor® stent and the ramus was then treated with a 3.5 by 9mm Endeavor®.  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?  Answer:  Again, the patient is still morbidly obese, and he is not diabetic.  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.  This was done via the right radial artery two months after the original presentation.  We used an Akari 2.0 guide and crossed the lesion with a Provia wire (Medtronic, Minneapolis, Minnesota) and performed balloon angioplasty and placement with a 3.5 x 24mm Endeavor® stent. 

 

This patient raises several questions.  (1) when a patient has an acute coronary syndrome and has a total occlusion of one of the vessels, what is his prognosis?  From a recent study in the Netherlands, his prognosis is very poor at 30 days, as well as at five year follow up so he is best treated with something since his prognosis without treatment is so horrible.  (2) What about a patient who has just undergone a major operative procedure who is again almost 200 pounds overweight, what about the performance of acute coronary bypass in a patient in this subset?   We felt in this case this was better treated by percutaneous intervention simply because all the lesions were approachable, including the chronic total, which in our hands can be successfully treated with a 90% success rate[1].  Lastly, the patient had all these procedures done radially which is particularly easier in a patient who is morbidly obese and recently found out from the RIVAL[2] study that in experienced hands the likelihood of major cardiac event is less compared to the groin procedure in sites such as ours that are very experienced in radial procedures.

 

Cases like this will be discussed at our meeting at the Wynn Encore Hotel in Las Vegas, on September 9-10, 2011.  At this meeting Ron Waksman, as well as Michael Mack will be discussing three vessel coronary disease and its therapy in regard to the context of the SYNTAX Trial.  On September 11, 2011, we are pleased to announce that with co-sponsorship with SCAI, we also will be offering a transradial interventional training program with several worldwide leaders in this technology, including Mehrdad Saririan, Ian Gilcrest and Tift Mann.  For information, please do not hesitate to contact [email protected].

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[1] 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.

 

[2] Sanjit S Jolly, Salim Yusuf, John Cairns, Kari Niemelä, Denis Xavier, Petr Widimsky, Andrzej Budaj, Matti Niemelä, 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.