54 year old female patient a known case of cad old asmi ,type 2 Dm, htn was admitted under diabetologist with abdominal pain ,found to have calculous cholecystitis was advised lap cholecystectomy by surgeon ,saw for surgical fitness pt had exertional angina also .I did cag for surgical fitness which showed SVD in lad critical.so far discussion how many would have stented then later gone for non cardiac surgery or how many would have done the other way ?

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I tend to disagree sir , here aS per CAG MOST CRITICAL part is mid LAD That too 80 percent. There is no mortality benefit . Had it been prox LAD RECENT EVENT AGREED. Pt admitted for abdominal pain , on enquiry we found effort angina. With long lesion and long stent with ANTIPLATELET INTERUPTION more chances of ST . I do agree with recent generation stent after 3 month ANTIPLATELET INTERUPTION is ok ? But can we GUARENTEE that event will not happen?if plaque is stable without touching it with OMT THERE WOULD HAVE BEEN LESS CHANCES FOR ACS. With DM SYMPTOMATIC CALCULOUS CHOLYSTESIS IS ALSO SERIOUS CONSIDERATION . Pt came for that . Luckily she got settled . Sir just tell me as per COURAGE we could have managed her with medicines ( which no cardiologist follows) so just my opinion it could have been lap cholecystectomy at centre with 24 7 Cath lab. Max dose of statin b blocker . After lap cholecystectomy elective PCI
Dr Vignesh sir if image 3 is pre intervention.if yes then it is mid LAD LESION WITH say 80 percent stenosis with effort angina .if no recent worsening no unstable angina no event in last 6 month , then optimal medical management , b blocker high dose statin, lap cholecystectomy at centre with PCI facility . Then once pt recovers then ptca . If ACS in recent then it will be complicated . U STENTED it . But now what about platelet interruption .with this long segment lesion its DES I GUESS ? If stable effort angina I will not stent it prior to lap cholecystectomy as per guideline
Dr Vignesh agreed .... But we as cardiologist are doing aggressive trearment. It is more of oculostenotic reflex. 90 percent of cardiologist would have STENTED it. But as per guideline ESC ACC DECREASE v trial enrolled high risk pt with extensive ISCHAEMIA on DSE ,58 percent had TVD .there was 32 percent event on medical treatment and 40 percent with Revas .prophlylactic Revas not indicated ... This is truth we cardiologist do more aggressive treatment and we should accept this ...
was unstable angina like situation all recent generation DES like xience alpine or expedition have DAPT drug interruption after 3 months if necessary where in hospital set up with Cath lab we can continue asa until 24 hrs of procedure and we can hold clopilet it's been more than 40 days of stenting and her abdominal symptoms are better
we have all back up and only treating cardiologist knows the scenario and pt had unstable angina and surgeons were skeptical and so was the patient take my word she is on regular follow up her abdominal symptoms are better I would not have done it if not symptomatic as life would have been easier, I fully agree with your inputs Dr
I would have also preferred the easy way out but as u know practice is difficult I had another pt with Pontine hge with stemi rca had 100% thrombus did suction and stented as surgeon refused pt also had lcx and lad did well
STENTING result good . But what about DAPT INTERUPTION? I feel here it has to be lap cholecystectomy then STENTING.ideally STENTING only if pt symptomatic on maximum OMT( courage trial) but no cardiologist follows that
it's not advisable with critical LAD lesion to go ahead with lap cholecystectomy pt had multiple gb stones it's tricky situation but I always feel if cardiac is more important than do it if not wait
Just my opinion sir I feel as per ESC ACC GUIDELINe here it should have been lap cholecystectomy f/b interval LAD STENTING. Will like to have others opinion evidence based
Agree with Santosh sir...
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So lap cholecystectomy after 3 month . Do u use GPIIB III a or clexane in interrupt period . I feel doing lap cholecystectomy with Cath lab would have made life easy
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