1. Call for CASES Staged PCI in a patient with multivessel coronary disease disqualified from CABG. Pawel Buszman, MD, FESC, FSCAI Marcin Debinski, MD Krzysztof Milewski American Heart of Poland, Ustron, Poland & CCU, Upper-Silesian Heart Center Silesian Medical School Katowice, Poland Staged PCI in a patient with multivessel coronary disease disqualified from CABG. Pawel Buszman, MD, FESC, FSCAI Marcin Debinski, MD Krzysztof Milewski American Heart of Poland, Ustron, Poland & CCU, Upper-Silesian Heart Center Silesian Medical School Katowice, Poland

2. Introduction PCI and CABG offer similar long term results (in respect to MI and death) in patients with moderately advanced coronary artery disease (CAD).PCI and CABG offer similar long term results (in respect to MI and death) in patients with moderately advanced coronary artery disease (CAD). There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical intervention.There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical intervention. Technological progress in interventional cardiology together with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease.Technological progress in interventional cardiology together with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease. PCI and CABG offer similar long term results (in respect to MI and death) in patients with moderately advanced coronary artery disease (CAD).PCI and CABG offer similar long term results (in respect to MI and death) in patients with moderately advanced coronary artery disease (CAD). There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical intervention.There are very few information on effectiveness of PCI in patients with diffuse CAD and high risk of surgical intervention. Technological progress in interventional cardiology together with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease.Technological progress in interventional cardiology together with advances in pharmacology should result in better outcome in patients with end stage coronary artery disease.

3. Description of the problem Male, 76 years old Unstable Angina, class CCS IV Medical history: 2xMI (1994-nonQ anterior, 2003-inferior wall) CAD Risk factors: HA, family history, former smoker LVEF 40% EUROSCORE 13 points: –age 4 pt –unstable angina after AMI 2 pt –peripherial atherosclerosis 2 pt –paroxysmal FA 3 pt –chronic obstructive pulmonary disease1 pt. –respiratory insufficiency1 pt.

4. Description of the problem Coronary arteriography: RCA: 60% stenosis in prox. RCA, 99% narrowing in med segment LCA: LM-diam. ca 3.5-4 mm, length 15mm, LAD-30% prox.lesion; critical, long, calcified, tortous lesions in med and distal LAD, Cx-90% type A lesion in prox, 99% type B2 lesion in distal segment. RCA LAO60 LCA: RAO 30 LCA: LAO60/cran25

5. Intended strategy Multiple, stage PCI with continous control of previously dilated vessels/segments. Use of bare metal stents to minimize costs of procedures. Carefull evaluation of contrast volume used for each procedure and renal function before/after eache stage. Concomitant pharmacological treatment: ASA 150mg o.d., clopidogrel 75mg o.d., ACEI, selective beta-blocker, statins,

6. First stage Right coronary artery (RCA) in LAO 60, before and after PTCA. Aug’2003: Predilatation of critical lesion in med RCA (balloon 3.0x20mm) and stenting of prox/med. segment (stent Chopin, Balton, 3.5x34mm, 18 atm). No complications. Hospitalization 6 days.

7. Second Stage Fig 1. Left coronary artery (LCA) in LAO 60, before and after PCI to Cx. Sept’2003: RCA: non-significant narrowings in med segments. PCI to Cx: POBA of distal lesion and predilatation and stenting of prox lesion (Chopin 3.0x8mm, 18 atm.) No complications. Hospitalization 3 days.

8. Third Stage Dec’2003: RCA: patent and large vessel, non-significant narrowing in med segments. Cx: restenosis in distal segment (75%). PCI to LAD: predilatation (balloon 1.5x20 & 2.0x20mm) and stenting of med/distal LAD (Multilink Zeta, 18 atm.). VF during stent implantation, successfully defibrillated within 15 s (1x300W). No further resuscitation or intubation required. PCI to Cx: POBA of distal restenotic lesion (balloon 2.5x20mm), residual stenosis<30%. Lab tests: Troponin I 1.04ng/ml; CK 337 U/l, CKMB 31 U/L. Hospitalization: 4 days.

9. Third Stage Fig 1. Left coronary artery (LCA) in LAO 60, before and after PCI.

10. Fourth Stage LCA: RAO 30 RCA: LAO 60LCA: LAO20/cran25 March’2004: A control angio revealed patent coronary arteries without significant stenosis.

11. Follow-up 9 months after the first stage we noticed: No significant stenosis in coronary arteries LVEF improvement (55%) Decrease of angina symptoms (CCS I) Improvement in quality of live, NYHA class II No further intervention requiered. Further intensive pharmacological treatement: statins beta-blocker ACEI ASA

12. Conclusions Stage PCI is a rational alternative to CABG in patients with advanced coronary artery disease and high risk of perioperative complications. In patients undergoing POBA or bare metal stent implantation a routine follow-up angio should be considered. Stage PCI offers opportunity to review previously dilated/stented coronary segments. It may limit obligatory use of DES.