Case presentation

An unfortunate 54-year-old man experienced numerous complications from paraplegia as a result of a gunshot wound at age 18. He has a neurogenic bladder with an indwelling catheter, and underwent resection of the left proximal femur following hip disarticulation. He has had multiple debridement and surgical procedures on chronic sacral decubitus ulcers. The most recent surgery, performed 2 weeks earlier, consisted of a gluteal flap.

While recuperating from this surgery, he developed a left facial droop and left arm weakness and also reported profound dyspnea but no chest pain. The neurologic symptoms resolved after a few hours but dyspnea continued. An electrocardiogram found lateral lead ST depressions and serial troponins were elevated, peaking at 17.54 ng/mL. Echocardiography uncovered severely reduced left ventricular function and a chest X-ray revealed congestive heart failure. He was diagnosed with a non-ST segment elevation myocardial infarction and heart failure; the transient ischemic attack was thought possibly due to a cardiac embolism. Although cardiac catheterization was indicated, the plastic surgeons advised against lying on his back side because pressure on the graft might jeopardize the viability of the gluteal flap. His extensive past medical history is also notable for prior myocardial infarction, diabetes mellitus, dyslipidemia, nephrolithiasis, and depression.

He was treated medically with aspirin, clopidogrel, beta blockers, and nitrates, and ultimately became stable with no further cardiac or neurologic symptoms. Surgery recommended that he continue to avoid lying on his back side for at least 2 more weeks. His physician decided to postpone catheterization for about 4 weeks to allow his decubitus graft to heal. However, 2 weeks later, he developed acute-onset shortness of breath and was admitted with pulmonary edema. He was referred for cardiac catheterization.

Cardiac catheterization

Obtaining arterial access proved challenging as his longstanding paraplegia resulted in substantial lower extremity atrophy and contracture at the hip. The femoral pulses were barely palpable; however, the right femoral artery was finally accessed successfully using ultrasound guidance, and angiography showed a small, diseased external iliac (Figure 9-1). The right coronary artery was without significant disease (Figure 9-2). Upon engagement of the left coronary artery, the operator observed pressure damping and ventricularization. The left main stem was severely diseased at the ostium (Figures 9-3, 9-4 and Videos 9-1, 9-2). In addition, there was significant obstructive disease noted in the proximal left anterior descending (LAD) and circumflex (LCX) arteries.

FIGURE 9-1 The femoral and external iliac vessels were very small and diffusely diseased.

FIGURE 9-2 There was moderate atherosclerotic disease in the right coronary artery.

FIGURE 9-3 The ostium of the left main stem was severely narrowed (arrow) and there was a high grade lesion of the proximal LAD (double arrow).

FIGURE 9-4 There was also severe disease of the circumflex artery (arrow).

A cardiac surgeon reviewed his medical history and deemed him a very poor surgical candidate because of his substantial comorbidities. After discussion about the options of continuing medical therapy versus a high-risk percutaneous coronary intervention, the patient agreed to proceed with a stenting procedure of the left main stem as well as the LCX and LAD lesions, primarily because he clearly failed a course of medical therapy.

The operator inserted an 8 French sheath in the right femoral artery and procedural anticoagulation was achieved with bivalirudin; he had already been on clopidogrel therapy. An 8 French, left Judkins guide catheter was engaged and floppy-tipped guidewires passed into the LAD and LCX. The lesions in the LAD and LCX were treated successfully with balloon dilatation followed by placement of paclitaxel-eluting stents (Figure 9-5).

FIGURE 9-5 The LAD and LCX were stented first, with an excellent angiographic result.

In order to protect the circumflex artery, the operator chose to use a modified “crush stent” technique to treat the left main stem lesion. Two stents were positioned in the left main/LAD and LCX: a 3.0 mm diameter by 20 mm long paclitaxel-eluting stent in the left main into the LAD, and a 3.0 mm diameter by 12 mm long paclitaxel-eluting stent in the circumflex (Figure 9-6). The left circumflex stent was deployed first (Figure 9-7