E-Science Station

Mr. NMN

We describe a 62 year old male with underlying hypertension, dyslipidemia, pervious history of ischemic stroke and CKD stage 3. He presented with recurrent episodes of pulmonary edema and resistant hypertension with systolic blood pressure >200 mmHg despite on 7 anti-hypertensive medications. He was also treated for NSTEMI during recent admission. There was presence of renal bruit and bibasal crackles of lungs. Other physical examinations were unremarkable.

Coronary angiogram showed moderate disease of distal LMS, severe stenosis of mid LCX, severe stenosis of proximal LAD and severe disease of posterolateral branch of RCA. In view of these findings, we referred him for CABG but surgeon declined due to resistant hypertension. He was then referred to vascular surgeon for bilateral aorto-iliac bypass but was turned down. We proceeded with Percutaneous Transluminal Angioplasty (PTA) of aorto-iliac, hoping that it will bring down the blood pressure.

We proceeded with Percutaneous Transluminal Angioplasty (PTA) of aorto-iliac with left brachial, right and left femoral artery punctures with 6FR sheaths. Attempted to cross with Terumo stiff wire and JR 3.5 6FR antegradely but wire was in the false lumen. Changed to retrograde approach via right femoral access and crossed with command 0.014 wire using SAFARI technique and wire externalized. Predilated and stented infra SMA into right external iliac and right common femoral artery with EPIC 14X60X7.0mm, ABSOLUTE PRO LL7.0X150mm and VASCUFLEX 7.0X80mm. We achieved good flow to right femoral artery but failed to cross left common iliac artery.
His blood pressure came down to 150/90 mmHg soon after the procedure and managed to reduce number of antihypertensives to 4 from 7. He had NSTEMI in the ward with dynamic ECG changes and dropped in LVEF to 38% from 53%. We proceeded with high risk PCI to LM-LAD and LCX.
PCI to LCX was done via right radial artery approach with 6FR sheath. Lesion was pre-dilated with 2.5X15 balloon and stented with DES 3.0x19 mm. It was post dilated with NC balloon 3.0x12 mm at 24 atm.
PCI to LAD with provisional single stent technique. Pre-dilated the lesion with NC 3.0x12mm and NSE Alpha 3.5x13mm. We were unable to deliver the long DES due to calcified and tortuous proximal LAD. We stented with DES 3.5x18mm and 3.5x26mm. It was post dilated with NC balloon 4.0x8mm at 20 atm. IVUS was done and result accepted.

We successfully managed to treat refractory hypertension and recurrent pulmonary edema through catheter intervention. We proceeded with peripheral intervention first in order to bring down the blood pressure prior to coronary intervention. Blood pressure control was essential to reduce the risk of haemorrhagic stroke during angioplasty. Patient was able to discharged well 3 days after the procedure. During subsequent follow up, he was asymptomatic with stable blood pressure and improvement of LVEF to 50%.