Case Report on Primary PTCA

Abstract:
Because CABG results in a significantly higher morbidity and prolonged hospitalization
in the older patient group, PTCA is an attractive alternative for providing myocardial
revascularization in the small group of older patients with appropriate lesions for
dilation. PTCA can be performed with acceptably low mortality and morbidity.
Therefore, PTCA may offer an alternative to CABG in the highly selected symptomatic
older patient.

Introduction:
Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous
coronary intervention (PCI) is a minimally invasive procedure to open blocked or
stenosed coronary arteries allowing unobstructed blood flow to the myocardium. The
blockages occur because of lipid-rich plaque within the arteries, diminishing blood flow
to the myocardium. The accumulation of lipid-rich plaque in the arteries is known as
atherosclerosis. When atherosclerosis affects the coronary arteries, the disorder
is known as coronary artery disease.  Patients with CAD usually present with exertional
chest pain, or with dyspnea with exertion. In acute myocardial infarction, there is
plaque rupture with platelet aggregation, and acute thrombus formation, which results
in a sudden occlusion of the coronary artery. These patients present with acute chest
heaviness, diaphoresis, and nausea. Urgent PTCA is often required to limit myocardial
damage.

Case Details:
A patient, 56 years old female, presented to E.R with a chief complaint of chest
pain since one day, Chest pain is felt like being stabbed through to the back, left
arm and neck. Chest pain was advancing since today morning early hours with a
duration of more than 20 minutes, and intermittent. There were no nausea, vomiting,
palpitations, shortness of breath, cold sweats or fainting
Patients had a history of suffering from diabetes since three years ago on regular
medication.

On physical examination found the general condition is weak with blood pressure
160/80 mm Hg, pulse 115 beats/min regular, respiratory rate 20 breaths/min,
auxiliary temperature of 37 C. At the head of the inspection found no abnormality.
On examination of the heart, the sound of S1-S2 single, regular, no sound is obtained
extra systoles, gallop, or murmur. On examination discovered pulmo-nary crackles. On
abdominal examination found no abnormality, normal bowel sounds.

On examination ECG shows ST elevations in antero lateral leads, 2D Echo shows distal
IVS, apex, anterior wall hypo kinetic, mild LV dysfunction, EF-45%. Troponin I +ve ,
Cath profile normal, Patient diagnosed as CAD-ACS Extensive AWMI. She was started
on NTG Infusion, Loading dose given.

Performed CAG & found CAD double vessel disease, Primary PTCA DES TO LAD
done. Her condition did not worsen during course of the hospital stay and was
discharged in a stable condition.

Discussion:
the main factor that determines the outcome of PTCA for occlusion is duration of
occlusion i. e the age of the lesion. Thus, older lesions are less likely to be crossed with
the guidewire.
With present technique and sufficient operator experience, 70% to 80% of total occlusion
could be successfully recanalized by coronary angioplasty with a lower complication
rate.
Precautions should be taken with dilatation of completely occluded arteries. First,
perfusion of the myocardium in the distribution of the occluded vessel relies on the
remaining coronary vessels. Care must be taken to avoid trauma to the non dilating
segments that supply these vessels. Second, it is important to visualize the course of the
distal vessel and thus determine the proper route for the dilating catheter. This may be
possible by reviewing films before the time of complete occlusion or by visualizing the
distal vessel by way of collateral channels.

Conclusion:
PTCA of total coronary artery occlusion can be performed safely and effectively in
selected cases and might be more successful in the lesion with shorter duration of
occlusion. But total coronary occlusion is the main limiting factor of PTCA with guide
wire technique. New technique has been developed to achieve the higher success rate
for the recanalization of chronically occluded coronary arteries, such as low-speed
rotational angioplasty or laser angioplasty. And the long-term clinical and angiographic
follow-up in patients having successful recanalization of an occluded coronary vessel
should be done to determine the long-term benefit of the procedure.