Complex Intervention For Hemodialysis Patient Department of Cardiovascular Medicine Saga University Mitsuhiro Shimomura TCTAP 2012
Case A 77 year old female had been treated with hemodialysis(hd) for chronic renal failure, peripheral vascular disease and had a history of Coronary Artery Bypass Graft ( LIMA LAD D1, RIMA LAD, GEA RCA #4PD ), Percutaneous Coronary Intervention (RCA seg1, LCX seg11, seg13 ) and Carotid Endarterectomy ( left internal carotid artery). She felt leg fatigue and lumbago under the distance of 50m when walked. Recently, she felt chest pain with the light activity and during HD. So she was admitted to our hospital for Unstable Angina Pectoris. TCTAP 2012
Physical examination Height:152.2cm Weight:51.3kg PR:56/min, regular, BP:132/60mmHg Systolic murmur ( Levine 3/6 ) was audible in the 2RSB. Arteriovenous shunt existed at the left antebrachium. Both femoral arteries were not fully palpable. Not palpable at below the popliteal artery. Fontaine classⅡ TCTAP 2012
Labo data WBC RBC Hb Ht MCV MCH PLT PT APTT PT INR Fib TP Alb 9800 /μl AST 16 IU/l BUN 29.2 mg/dl 361 x10 4 /μl ALT 11 IU/l Cr 6.80 mg/dl 11.7 g/dl LDH 163 IU/l egfr 5.1 ml/min 36.5 % T Bil 0.3 mg/dl Na 142 meq/l 101.1 fl γ GTP 19 IU/l K 4.1 meq/l 32.4 pg ALP 283 IU/l Cl 102 meq/l 21.2 x10 4 /μl Glu 96 mg/dl Ca 10.4 mg/dl 95.2 % HbA1C 5.1 % I P 3.3 mg/dl 93.99 % CPK 43 IU/l CRP 140mg/dl 1.40 1.00 CPK MB 5 IU/l NT probnp 8244 pg/ml 921.0 mg/dl T CHO 148.4mg/dl 72g/dl 7.2 TG 142 mg/dl 3.5 g/dl HDL CHO 42 mg/dl LDL CHO 78 mg/dl UA 48 4.8 mg/dl TCTAP 2012
ECG & Chest X ray CTR:55% TCTAP 2012
CT 2009.11 TCTAP 2012
UCG Aod LAD IVS PW LVDd LVDs LVEF :30mm :35mm :12mm :12mm :43mm :28mm 64% LVEF :64% AVA Peak AoV Ao LV PG :0.99cm 2 :3.90m/sec :61mmHg Aortic valve:calcification(+) Mitral valve: calcification(+) (Mitral ring calcification) AR mild, MR trace TR none, PR none TCTAP 2012
CAG TCTAP 2012
CAG TCTAP 2012
PCI 1 TCTAP 2012
PCI 1(RCA) Sapphire II TM Rotablator 1.5x15mm 1.5mm Rotablator PROMUS 2.0mm 3.5x23mm TCTAP 2012
Clinical course1 During hemodialysis, the blood pressure decreased, bradycardia appeared and she felt chest oppression. The remaining stenosis was considered the cause of ischemia. To ensure get the approach for PCI, we needed to perform the angioplasty for abdominal artery. TCTAP 2012
EVT 1 (Lt. Common Iliac Artery) CREST TM 7.0x20mm SMART contol TM 7.0x40mm CREST TM 7.0x20mm TCTAP 2012
1 1 2 2 3 4 5 3 4 5 <Pressure gradient>> 49mmHg Proximal:184/37(86), Distal:135/28(72) TCTAP 2012
EVT 2 (Infra Renal Abdominal Aorta) SMART contol TM 10.0x30mm 0x30mm CREST TM 7.0x20mm TCTAP 2012
1 1 2 2 3 4 5 3 4 5 Pressure gradient disappeared TCTAP 2012
PCI 2(LCX) Integrity 2.25x22mm25x22mm TCTAP 2012
EVT 3 (Rt. External artery) SMART contol TM 6.0x40mm CREST TM Pressure 6.0x20mm gradient disappeared <Pressure gradient> Proximal:191/44(97), Distal:160/43(91) TCTAP 2012
Clinical course2 Chest oppression disappeared during effort. Walking distance has got longer over 75m without lumbago and leg fatigue. TCTAP 2012
Summary The aggressive interventions for the general severe atherosclerotic lesions led to the significant improvement of the patient s Activities of Daily Living. TCTAP 2012