Give Your Patient the Correct Stent

I used to hold the opinion that adequate vessel sizing could by accomplished through cardiac angiogram visualization alone. That opinion changed once our facility started using intravascular ultrasound (IVUS) on a regular basis.

Several years ago, in coordination with interventionalist Dr. Gaurav Aggarwala, we might view a specific cardiac angiogram and be somewhat uncertain as to the appropriate size of stent to deploy. Using an IVUS catheter to obtain intraluminal visualization, we soon found that correct sizing of a cardiac stent was slightly different than when based on angiogram visualization alone. From the time of that realization, we have routinely used IVUS when choosing stent size, whether it is placed in the peripheral or cardiac setting. One cannot truly appreciate the exact vessel anatomy or size without the use of IVUS technology.

Several weeks ago, I was working in the cath lab when the emergency room notified the lab of a patient presenting with severe chest pain. The patient said that he had undergone an angiogram in a neighboring city during the occurrence of his previous myocardial infarction two weeks ago, resulting in a stent being placed in his left anterior descending artery (LAD). He also said that the pain he was currently experiencing felt precisely the same as the chest pain from its previous occurrence. The cath lab was immediately activated to perform an emergent cardiac angiogram. After obtaining arterial access, the first vessel to be visualized was the right coronary artery, since the patient had reported his left coronary system as having previous intervention. The right coronary was patent and did not require intervention. The patient, when asked if he was compliant with his medication regimen, reported he had faithfully been taking his medication, including clopidogrel. The left coronary system was then visualized under fluoroscopy, and it was discovered that the previously placed stent in the LAD was 90% occluded, primarily due to the placement of an undersized stent. IVUS indicated that the vessel had a 3.5 mm lumen with a 2.5 mm stent.

At this point, clot was aspirated from the vessel and a balloon delivered to maximize the stent’s potential. A drug-eluting stent was placed within the old stent and inflated fully to the inside of the original stent. IVUS confirmed the stent was apposed correctly.

As this case so clearly demonstrates, without the ability to visualize the true lumen of a vessel, the chance for reocclusion or malapposition is greatly increased. The clinical scenario we describe resulted in further myocardial damage for this particular patient. We owe it to our patients to protect and preserve cardiac function at the first opportunity.

I would like to recognize the intense work and dedication of Dr. Gaurav Aggarwala and the cath lab staff at Palestine Regional Medical Center. The new cardiac and peripheral program is a great asset to the community of Palestine, Texas. The administration team at Palestine Regional has been pivotal to meet the growing needs and demands of providing comprehensive and quality cardiac intervention.

If you have a subject you would like covered, or area of interest, please contact Phillip Mumford, RCIS, at cathmedic@aol.com.