Transcript HPI

Early Stent Complications
Anand Irimpem, M.D.
Robert Smith, M.D.
Cardiac Cath Conference
November 5, 2003
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 34 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
PMHx
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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
Medications
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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
Family History
• Father suffered non-fatal MI at age 77
Social History
• 60 pack years of cigarette smoking (current
smoker)
• Occasional EtOH use
• Denies drug use
Physical Exam
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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
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
ECG
Normal
Summary
48 yo male with multiple risk factors for
CAD, typical chest pain, and new onset
heart failure
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).
Early Stent Complications
• Failed Delivery (with potential
embolization)
• Stent Thrombosis
• Coronary Spasm
• Side Branch Occlusion
• Intramural Hematoma (coronary dissection)
• Coronary Perforation
Failed Delivery
• Stent loss with 1st generation stents occurred in 28% 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 cases2
• Complications include peripheral embolization,
dislodgement into left main
1Am
J Cardiol 2000
2Am J Cardiol 1999
Stent Thrombosis
• Usually occurs in the first 24 hours (acute) or within the 1st
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
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’s1
• 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
1Circulation
2002
Coronary Perforation
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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
inflations1 or hydrophilic coronary guidewires
1Am
J Cardiol 1996