44: Crush Stent or Provisional Stenting for Bifurcation Lesion?

CASE 44 Crush Stent or Provisional Stenting for Bifurcation Lesion?




Case presentation


A 52-year-old man with end-stage renal disease, on dialysis for 5 months, developed ventricular tachycardia during vascular access surgery for dialysis. Past history was notable for longstanding and poorly controlled hypertension leading to end-stage kidney disease and a history of systolic heart failure, with an echocardiogram showing global left ventricular dysfunction and ejection fraction of 35% to 40%. He underwent cardiac catheterization 5 months earlier when he first presented with heart failure in the setting of renal failure, and was found to have a normal right coronary artery (Figure 44-1), a normal circumflex system, and moderate disease in the left anterior descending (LAD) artery just after the first septal perforator, but he also had a severe stenosis of the ostium of a large diagonal branch (Figures 44-2 through 44-4 and Video 44-1). Based on this evaluation, his heart failure and systolic dysfunction were thought to be secondary to the renal failure and hypertensive heart disease, with coexisting coronary artery disease. He was treated medically with lisinopril, metoprolol, aspirin, and amlodipine and did well until he developed sustained polymorphic ventricular tachycardia and chest pain during AV fistula graft placement for dialysis. This episode required resuscitation with cardioversion and intubation. Sinus rhythm was restored and subsequent electrocardiograms showed no acute changes but serial troponin I assays were elevated, consistent with a non-ST segment elevation myocardial infarction. He was loaded with clopidogrel and referred for repeat coronary angiography with the plan to treat the diagonal lesion previously observed.






Jun 11, 2016 | Posted by in CARDIOLOGY | Comments Off on 44: Crush Stent or Provisional Stenting for Bifurcation Lesion?

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