Contemporary treatment of coronary artery disease is highly dependent on percutaneous coronary intervention (PCI) along with medical management. PCI techniques have advanced significantly over time and are used to stent even difficult lesions. There are, however, some lesions which present challenges via conventional PCI route. These lesions, termed complex coronary lesions are categorized as such based upon various anatomic, physiological, or functional difficulties.
Some of these complex lesions in coronary vessels include bifurcation lesion, calcified lesions, chronic total occlusions, unprotected left main coronary artery lesions, ostial lesions, or stenosis of the saphenous vein graft. Each of these lesions presents unique challenges and approach to such lesions is individualized. Specialized techniques, as well as cardiologists with more advanced skill sets, have improved successful treatment of such lesions.
Conventional PCI may not adequately resolve these lesions, and some may require advanced techniques. One such subset of advanced catheter oriented interventions is termed: complex high-risk and indicated PCI (CHIP). Such techniques are reserved for individuals who are very high risk for complications. Examples of these techniques include laser, rotational, and laser atherectomy, various bifurcation stenting techniques, and specialized approaches to chronic total occlusions. These techniques are promising; however, studies are inconclusive if they have a positive impact on mortality. Some studies such as one from Habib et al. cite CABG as a more effective modality towards addressing these lesions.
A brief explanation of some of the most common complex lesions follows.
Each complex coronary artery lesion has a unique set of etiologies. For example, bifurcation lesions are primarily anatomic-based. Coronary artery calcifications can result from inherent inflammatory processes, as well as the activity of osteoblastic activity. Presence of thrombus can often result from plaque disruption before or during PCI. Saphenous vein graft occlusion is thought to be a process of intimal vessel smooth muscle proliferation. There are disease processes which are common to each disorder. For example, Baris et al. identified diabetes mellitus and advanced age as independent predictors for all complex coronary lesions. Each process has an individual process which contributes to its etiology. Other risk factors for coronary artery disease and atherosclerosis such as age, hypertension, obesity, male sex, smoking, and hypercholesterolemia can be inferred, but have not directly been identified in any significant studies as independent risk factors for all complex lesions.
Coronary bifurcation lesions are the most common of the complex coronary lesions. Some estimates have reported that these are found in up to 20% of all PCI’s.
Most individuals with these lesions present similarly. The most common presentation is with angina pectoris given the occlusive nature of these coronary processes. Essential history elements include evaluating for risk factors of coronary artery disease. It is crucial to ask the patient questions regarding the history of any form of vascular disease, family history of heart disease, obesity, diabetes, hypertension, age, hyperlipidemia, and smoking history. Some of the most common symptoms of these lesions include:
Physical examination findings will vary based upon the status of the patient’s disease. Individuals can have chronic coronary artery disease or an acute unstable plaque, and their physical exam findings will manifest in completely different ways. Thus, it is important to evaluate each case distinctly when doing a physical exam. Some items to look for in the physical exam include:
Evaluation should include:
Treatment of primary coronary lesions varies with type:
Complex coronary lesions carry higher overall mortality in patients with stable angina than those with non-complex lesions. These complex lesions are often associated with diabetes, lower ventricular ejection fraction, lower HDL-C. The SYNTAX Score and SYNTAX Score II are frequently the means to decide on the best revascularization approach. Studies have shown SYNTAX Score II to be superior to the SYNTAX score as a tool of prognosis. The 4-year mortality showed an adequate correlation between score and mortality in patients with low and medium SYNTAX Score II, however, found that a high SYNTAX Score II underestimated mortality at four years.
Patients should be active participants in their care. Given the morbidity and mortality involved with complex coronary lesions, providers should actively discuss the management of these lesions as well as all possible options and the potential complications associated with them. Medical, interventional, as well as surgical options, should be discussed with these individuals.
Management of complex coronary artery lesions requires a multidisciplinary, interprofessional team approach. Emergency medical personnel are often first responders and must be able to adequately screen for acute coronary syndromes. Nurses must be able to effectively recognize symptoms and decompensation of these patients at the bedside. Nurses and pharmacists are also needed to prepare, dispense, and efficiently administer various medications which may be necessary during these processes. Cath lab staff also play an essential role. Cath lab techs, as well as nurses, must be readily available to efficiently and effectively deliver care when acute coronary syndromes occur. And of course, interventional cardiologists play a vital role. Interventional cardiologists must be readily available to diagnose and treat those with complex coronary lesions. At times, interventional cardiologists may need to utilize advanced techniques in high-risk patients.
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