The use of modern interventional cardiology tools to verify lesion significance and optimize procedural outcome in a diabetic patient with multivessel disease

Introduction

Coronary artery bypass graft (CABG) surgery has been the preferred revascularization technique for multivessel coronary artery disease, particularly in patients with diabetes mellitus [1–4]. However, with the rapid progress in the field of interventional cardiology, percutaneous coronary intervention (PCI) has been widely used as a less invasive approach to CABG surgery, with encouraging results. Here we present the case of a patient with multivessel coronary artery disease who was managed by PCI using modern interventional tools to improve on diagnostic angiographic data and optimize the procedural result.

Case report

A 52-year-old man with a history of cigarette smoking, diabetes mellitus and old inferolateral myocardial infarction was referred to our institution for CABG surgery. Following the recent onset of epigastric pain and dyspnea, he underwent cardiac work-up. A resting electrocardiogram was normal. An echocardiogram demonstrated a mildly reduced left ventricular ejection fraction (LVEF) at 45% with hypokinesis of the inferolateral wall. A coronary angiogram done at the local hospital reportedly showed evidence of severe 3-vessel disease.
On review of the coronary angiogram at our institution, the dominant right coronary artery (RCA) demonstrated a hazy lesion suggestive of a ruptured plaque in its proximal segment along with severe stenosis in its third segment (95%). The left circumflex (LCx) artery showed severe narrowing in its proximal (80%) and mid segments (99%), the latter at the take-off of the first obtuse marginal (OM1) branch, which also demonstrated severe ostial disease (85%). The left anterior descending (LAD) artery exhibited long lesions in the proximal and mid segments, visually in the 60–70% stenosis range (Figure 1 A). The logistic Syntax score was calculated at 29%. The cumulative 2-year major adverse cardiac and cerebrovascular event (MACCE) rate is 16.4% by CABG and 22.8% by PCI. A fractional flow rate (FFR) study was done through the right radial approach to assess the hemodynamic significance of the LAD lesions (Figure 1 B). An FFR of 0.85 following hyperemia induced by intravenous adenosine through the left brachial vein confirmed the lack of physiological influence on coronary flow. Therefore a clinical decision was made favoring a staged percutaneous revascularization over CABG. An intravascular ultrasound (IVUS) study was then performed on the proximal RCA lesion (Figure 1...


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