Cath Lab Digest - October 2007 - (Page 27)

OCTOBER 2007 CASE REPORT 27 DRUG-ELUTING STENT SOLUTIONS Release from Stent-jail: Beneficial Snow-Plowing? Jack P. Chen, MD, FACC, FSCAI, FCCP Chairman, Department of Cardiology, Northside Hospital Atlanta, Georgia Patient Management Guidelines This monthly column in Cath Lab Digest reviews important points of distinction in drug-eluting stents, from characteristics to techniques, to provide valuable and relevant information about this technology. By Dr. Bonnie Weiner Bonnie Weiner, MD, MSEC, MBA, is the president of the Society for Cardiovascular Angiography and Interventions (SCAI). She is a physician at Saint Vincent Hospital and Fallon Clinic in Worcester, Mass., where she is an integral part of the catheterization lab team and regularly performs all types of catheter-based procedures including angiography, angioplasty and stenting. She is board-certified in internal medicine and cardiovascular disease as well as interventional cardiology. Q A What are patient management guidelines, and how are they set? In cardiology, guidelines are typically set by an organization when a sufficient body of evidence exists for the treatment of a specific disease state. Guidelines are also used as guiding principles for a certain procedure or procedural group, such as percutaneous intervention. A working group is then established that includes representatives from all of the major groups that have influence upon or interest in that particular area. The working group reviews available data and weighs it in terms of how helpful the data is, taking into account how well each trial was conducted. For example, large randomized clinical trials are rated the highest, while small registries and case reviews are rated the lowest. Final recommendations are made based on the quality of the available data and its consistency. If there are no clear data, then the working group comes up with a consensus. How are guidelines typically used by practitioners? Guidelines should be used to help practitioners determine how they should treat patients. Clearly, every patient is unique and may not represent the information that goes into the development of a guideline, so there is always an interpretation of how a specific guideline should be applied to a specific patient. But, in general, guidelines are used to help practitioners, as well as institutions, develop policies and procedures for dealing with patient groups. These guiding principles are meant to filter down to an individual patient as appropriate. When do guidelines usually get updated? Guidelines are typically updated when there has been a significant change in the available data, for example, a clinical update or policy change. A formal guideline update is a very long, laborious effort, so there must be an accumulation of data that modifies the standing guidelines. Sometimes this takes five years or more. What role does SCAI play in patient management guidelines? Our role is to provide quality guidance and education to our 4,000 members, all of whom are interventionalists. We take this role seriously and are trying to expand it so we can reach more of the people who take care of our patients. SCAI’s mission is to promote excellence in invasive and interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. We keep our members updated on guidelines and clinical information via mailings and our journal, Catheterization and Cardiovascular Interventions. continued on next page Introduction We hereby present a case of distal right coronary stent deployment across a previously undetected ostial occlusion of the posterolateral branch during an acute myocardial infarction. Repeat catheterization at 18 months subsequently revealed an open stent with a newly patent side branch. While many techniques have been proposed to avoid side-branch occlusion with “stent-jail,” our case illustrates the rare opposite occurrence of incidental and spontaneous side branch “jail-break.” Case Report A 56-year-old woman presented with an acute inferior ST-segment elevation myocardial infarction. She was treated with intravenous metoprolol, heparin and eptifibatide, along with oral clopidogrel and aspirin. Emergent cardiac catheterization revealed a thrombotic total occlusion of the mid to distal right coronary artery (Figure 1), with no Q A significant disease of the left coronary system. Left ventricular function was mildly depressed with mild inferior hypokinesis. Percutaneous coronary intervention proceeded with easy wire passage and immediate but faint opacification of the distal vessel. An Export thrombectomy catheter (Medtronic Inc., Santa Rosa, CA) was advanced distally over the guide wire. Subsequent pretreatment with intracoronary nitroprusside (total of 200 mcg) was then administered into the distal coronary through the aspiration lumen, according to previously described methods.1 Three runs of manual Export aspiration were conducted with recovery of a small quantity of thrombotic material. The distal vessel was now visualized, with Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, revealing a 90% stenosis at the site of previous occlusion. A 3.0 x 16 mm Taxus drug-eluting stent (DES) (Boston Scientific Corporation, Natick, MA) was easily deployed (Figure 2), Q A Q A Figure 1. Emergent coronary angiography revealing a thrombotic occlusion (arrow) of the distal right coronary artery.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

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