1. Early Stent Complications Anand Irimpem, M.D. Robert Smith, M.D. Cardiac Cath Conference November 5, 2003

2. HPI Pt. is a 48 yo white male with PMHx significant for HTN, DM, Hyperlipidemia, who presented on referral from outside hospital for new onset heart failure. Pt presented to the outside facility with 2 month h/o progressive DOE, LE edema, orthopnea, and PND. He was diuresed and discharged with f/u at Charity. Pt also reported 3- 4 month h/o exertional chest discomfort that occurred with walking approximately 40 yards. This discomfort radiated to his left arm and neck and occasionally was associated with diaphoresis. Pt. denied N/V, SOB

3. PMHx DM X 5 yrs. HTN X 15 yrs. Hyperlipidemia Reports hospitalization 1 yr prior for CP with “positive blood test” indicating heart attack. (never followed up) C5/C6 fusion 1995 History of Herpes Zoster Anxiety

4. Medications Glyburide/Metformin 1.25/250mg BID Monopril 20mg QD Coreg 7.5mg BID Lipitor 10mg QD Elavil 25mg QHS Lasix 20mg QD Methocarbamol 1750mg QID Wellbutrin 150mg BID

5. Family History Father suffered non-fatal MI at age 77

6. Social History 60 pack years of cigarette smoking (current smoker) Occasional EtOH use Denies drug use

7. Physical Exam 138/84 76 12 98.6 NAD JVP 8cm, no bruits nlS1S2, no murmurs, +S4 gallop Clear lung fields NABS, NT, ND, liver palpable 2cm below costal margin No edema DP, PT pulses 3+ bilaterally

8. Labs Na 139, K 4.3, Cl 105, HCO3 27, BUN 9, Cr 0.6, Glu 158 WBC 7.7, HGB 14.4, HCT 41.6, PLT 218, MCV 93, N 47%, L 37% PTT 29.6, INR 1.0 Tchol 174, TG 108, HDL 30, LDL 132

9. ECG Normal

10. Summary 48 yo male with multiple risk factors for CAD, typical chest pain, and new onset heart failure

11. The patient was taken to the cath lab where he was found to have an occlusive lesion in his proximal LCx artery (films shown). The lesion was successfully stented and appropriate anticoagulation therapy was administered. While being wheeled out of the cath lab, the patient complained of severe chest pain (approx 15 minutes after completion of the procedure). The ECG showed 2mm ST segment elevation in the inferolateral leads. He was emergently returned to the cath lab where repeat cath showed thrombus in the new stent with complete occlusion of the vessel (films shown).

12. Early Stent Complications Failed Delivery (with potential embolization) Stent Thrombosis Coronary Spasm Side Branch Occlusion Intramural Hematoma (coronary dissection) Coronary Perforation

13. Failed Delivery Stent loss with 1 st generation stents occurred in 2- 8% of cases Stent loss with second and third generation stents is 0.4 -2% 1 Serious adverse event (MI, death, urgent CABG) occurs in ~19% of cases 2 Complications include peripheral embolization, dislodgement into left main 1 Am J Cardiol 2000 2 Am J Cardiol 1999

14. Stent Thrombosis Usually occurs in the first 24 hours (acute) or within the 1 st week (subacute) With high pressure deployment and antithrombotic treatment, incidence is 0.9-2.5% 1 Risk factors are numerous and include emergent placement, small caliber vessel, incomplete expansion, total stent length, subtherapeutic anticoagulation, and LV dysfunction 30 day mortality after stent thrombosis is as high as 26% 2 1 J Am Coll Cardiol 2001 2 Circulation 2001

15. Intramural Hematoma Defined as accumulation of blood within the wall of the vessel with or without identifiable entry and exit points Occurs in 6.7% of PCI’s 1 Has angiographic appearance of dissection 60% of the time Incidence is lower with stenting when compared to PTCA Pt’s with hematoma had same incidence of NQWMI as those without, but higher incidence of revascularization within 1 month 1 Circulation 2002

16. Coronary Perforation Incidence is as high as 0.4% Mortality is as high as 14% Manifestation is delayed in approximately 20% Features associated with stent related perforation include complex lesion morphology, small vessel diameter, oversized stents Can occur with use of high pressure balloon inflations 1 or hydrophilic coronary guidewires 1 Am J Cardiol 1996