CASE PRESENTATIONCASE PRESENTATION

ByDr. Khalid Iqbal BhattiPost Fellow

SequenceSequenceIntroductionClinical HistoryClinical ExaminationLabsImagesDiscussionFollow-up

Clinical HistoryClinical History52 YearsKnown case of diabetes mellitus

for 14 yearsKnow case of hypertension for 1

yearNon smokerNon AsthmaticNo previous History of IHD

Clinical HistoryClinical Historycontd…contd…Chest pain/heaviness for 3 to 4

hours radiating both arms relieved by nitrates

During admission pain recurred Associated with sweating

Clinical ExaminationClinical ExaminationPulse 72 beats/minBP 110 / 70 mmHgRR 22 breaths/minCVS UnremarkableECG ST depression in V2 – V5

LabsLabsTroponin less than 0.05

ng/mlRoutine investigations

Normal

SummarySummary52 yrs present with USA having

multiple risk factors and ECG changes

Recommended for Coronary cath

ImagesImagesCoronary Angiography

DiscussionDiscussion

Plaque shiftPlaque shiftThe lateral dislocation of plaque during dilatation therapy, which if directed towards a side branch, may occlude the ostium

Snow-plow injury Snow-plow injury a form of plaque shift that occurs at the carina of the bifurcation where plaque is dislocated from the parent vessel into the ostium of the side branch

Predictors  of  side Predictors  of  side  branch   branch  occlusionocclusionSeveral mechanisms are

responsible for SB compromising during bifurcation treatment:◦ Plaque shift “snow plow effect ”◦ Dissection of SB after balloon/stent

in MB◦ Spasm of SB◦ SB ostium jailing by stent struts◦ Carina stent-induced displacement

Characteristics of bifurcation Characteristics of bifurcation lesions PCIlesions PCI

Identification of Side Branch Identification of Side Branch at riskat risk

Identification of Side Branch Identification of Side Branch at riskat riskSB Occlusion during PCI

Plaque Shift At Plaque Shift At Bifurcation LesionsBifurcation LesionsPCI of Bifurcation lesion is

challengingSide-branch compromise in 9-67%

of casesProtection of side branches is time

consuming, associated with more contrast media, radiation, and increased risk of complications as dissection, perforation, CIN

In bifurcation lesions in which there is no significant involvement of the side branch, we cannot predict the fate of the side-branch after PCI

Plaque Shift At Plaque Shift At Bifurcation LesionsBifurcation LesionsIntra-coronary near-infrared

spectroscopy can identify lipid-core plaques using the Lipiscan (InfraRedx) system

Lipid-core plaques are soft, and prone to plaque shift during PCI

Side-branch compromise as a result of plaque shift is associated with increased rate of peri-procedural MI and other complications

Near-infrared spectroscopy can potentially help to identify bifurcation lesions that are in increased risk of side-branch compromise

Both plaque shift from the MB and carina shift contribute to the creation / aggravation of a SB ostial lesion after MB stent implantation.

The mechanism of side branch(SB) luminal narrowing after main branch(MB) stent implantation in coronary bifurcation lesions is not completely understood.

Management / ProtectionManagement / ProtectionAccurate stent positioningProtect side-branch with wireNitrates to exclude spasmKissing PTCA to side-branchStent occasionally requiredIVUS

Follow-UpFollow-UpClinically

◦No symptoms◦No serial ECG changes◦Vitally stable ◦Observe for 24 hours◦Glycoprotein IIb / IIIa inhibitor

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