1. One stage coronary and peripheral intervention Pawel Buszman, MD, American Heart of Poland, Ustron Silesian Medical School, Katowice

2. Case report Clinical data Male, 72 year old Male, 72 year old Unstable angina (CCS class 4) Unstable angina (CCS class 4) TIAs TIAs RISK FACTORS: -heavy smoker (30 cigarettes a day) -hypercholesterolemia RISK FACTORS: -heavy smoker (30 cigarettes a day) -hypercholesterolemia

3. Case report EKG: ST depressions in inferior leads EKG: ST depressions in inferior leads UKG: normal LV function UKG: normal LV function

4. Coronary and peripheral angiography LAO30: left CCA and ICA AP: aortic bifurcation and iliac arteries 99% CCA ICA

5. Coronary and peripheral angiography RCA: RAO30 90% LCA: RAO30 LM: 80% stenosis

6. Strategy of the procedure 1.Predilatation and stenting of mid. RCA 2.Direct stenting of LM 3.Predilatation and stenting of left ICA 4.Kissing stenting of aortic bifurcation

7. PTCA: RCA stenting RCA after stenting 6F guiding catheter Predilatation: balloon 2.5 mm Stent: Bx Velocity 3.0x18mm Max pressure 14 atm.

8. PTCA: LM-stenting Guiding Catheter JL6F Wire: BMW 0,014” Stent: BX Velocity 3.5x18mm Max. pressure 20 atm

9. Carotid stenting Long Sheath 7F Wire: BMW 0,014” Pre-dilatation: balloon 3.5 mm Stent: SMART 7x20mm Post-dilatation: balloon 4.5 mm

10. Kissing stenting of aortic bifurcation Bilateral, retrograde approche through 7F sheats. Direct stenting: 2xWallstent 10x45mm Postdilatation: balloons 2x8.0mm

11. Procedure protocol No of guiding catheters:2 No of guiding catheters:2 No of balloons4 No of balloons4 No stents5 No stents5 No of wires:2 No of wires:2 No of arterial sheats4 No of arterial sheats4 Contrast volume350 ml (non-ionic) Contrast volume350 ml (non-ionic) X-ray exposition19,5 min. X-ray exposition19,5 min. Procedure time110 min. Procedure time110 min.

12. Periprocedural outcome and long-term follow-up No procedure related complications No procedure related complications 48 hour hospital stay 48 hour hospital stay Normal renal function Normal renal function No recurrence of myocardial ischemia or TIA during 6 month follow-up No recurrence of myocardial ischemia or TIA during 6 month follow-up Normal daily activity Normal daily activity

13. 6 month control coronary angiography: LCA: RAO30 Stented segment

14. Discussion Why one-stage procedure? Why one-stage procedure? Unstable angina requiring myocardial revascularization Unstable angina requiring myocardial revascularization High risk surgical candidate High risk surgical candidate Critical ICA narrowing with TIAs Critical ICA narrowing with TIAs Risk of the inferior limb ischemia after the arterial sheath removal Risk of the inferior limb ischemia after the arterial sheath removal Repeat access to heart to be maintained! Repeat access to heart to be maintained!

15. Why a percutaneous procedure? The patient’s risk summary The substantial risk of: -AMI -sudden cardiac death -stroke -critical limb ischemia -surgical treatment -cardiac surgery -vascular surgery The substantial risk of: -AMI -sudden cardiac death -stroke -critical limb ischemia -surgical treatment -cardiac surgery -vascular surgery The risk of -LM stenting&restenosis -carotid stenting -renal failure -in-stent restenosis Pro Contra

16. Risk of stroke In symptomatic patients with severe narrowing of a common or internal carotid artery annual risk of stroke range between 20-30% In symptomatic patients with severe narrowing of a common or internal carotid artery annual risk of stroke range between 20-30%

17. Coincidence of CAD and PAD 30-50% of patients with PAD have coronary artery disease 30-50% of patients with PAD have coronary artery disease

18. Major cardiovascular events in patients with PAD – 5 year follow-up AMI, UA, Stroke20% AMI, UA, Stroke20% Death20-30% Death20-30% (PAD Detection, Awareness, Treatment and Primary care. JAMA 2001;286:1317-1324.)

19. Influence of PAD on long-term survival PAD Detection, Awareness, Treatment and Primary care. JAMA 2001; 286:1317-1324.

20. Prognosis in patients with severe PAD one-year mortality rate Critical inferior limb ischemia25% Critical inferior limb ischemia25% An inferior limb amputation45% An inferior limb amputation45%

21. Conclusions Long term survival after myocardial revascularisation can be limited by severe carotid and peripheral artery disease. Long term survival after myocardial revascularisation can be limited by severe carotid and peripheral artery disease. Cardiac cath lab should be prepared for a peripheral intervention. Cardiac cath lab should be prepared for a peripheral intervention. Interventional cardiologists should be routinely trained in those procedures. Interventional cardiologists should be routinely trained in those procedures.

22. Conclusions Drug eluting stents should enhance the safety of LM stenting. Drug eluting stents should enhance the safety of LM stenting.