Treatment of stenosing atherosclerosis of the coronary arteries and performing a right-sided nephrectomy within the framework of a single hospitalization
Analysis of a clinical case presented by Denis Vladimirovich Sokolov, Ph.D., a cardiologist at Medicina JSC (clinic of academician Roytberg)
Patient R. 73 years old.
Complaints
Complaints of recurrent pain in the area of the heart of a compressive nature, lasting up to 10-15 minutes, without irradiation, without connection with physical activity. Does not use nitro-preparations.
Medical history
She has been observed in the clinic of Medicina JSC since 2000. History of hypertension with maximum blood pressure up to 160/100 mm Hg. Art. Occasionally, I was bothered by pain in the area of the heart of a compressive nature, lasting up to 10-15 minutes, without irradiation and without connection with physical activity (I did not use nitro drugs). There are no indications of myocardial infarction or acute cerebrovascular accident. Previously, she took Concor - 2.5 mg in the morning, thromboass - 100 mg in the evening, Torvacard - 10 mg at night.
More than 20 years have been observed and treated for chronic pyelonephritis.
Postponed injuries and operations, chronic diseases
In 1989 - a car polytrauma with damage to the chest, skull bones, face (operated on).
Chronic obstructive pulmonary disease.
Chronic pyelonephritis, cysts of both kidneys.
Rheumatoid arthritis, seronegative polyarthritis, secondary coxarthrosis with symptoms of aseptic necrosis of the left femoral head.
Duodenal ulcer disease, stable remission.
Labor history: artistic director, denies professional hazards.
Smoking: currently does not smoke, previously had a long history of smoking.
The results of examinations in the clinic "Medicine"
Clinical blood test from 06.08.2011 - mild normochromic anemia.
Clinical analysis of urine from 06.08.2011 - no significant deviations.
B / x blood tests from 06/08/2011: type II A dyslipidemia (LDL level 3.8 mmol / L, HDL level 1.4 mmol / L), increased urea level to 8.7 mmol / L, creatinine up to 121 mmol / l (glomerular filtration rate according to CKD-EPI 38.2 ml / min / 1.73 m 2 ), decrease in the level of ionized calcium to 1.37 mmol / l.
ECG from 07/19/2011 - sinus rhythm, normosystole, deviation of the electrical axis of the heart to the left.
Echocardiography from 19.07.2011 - sclerotic changes in the aorta, aortic valve with the formation of unexpressed aortic stenosis and aortic insufficiency, wall thickness and dimensions of the heart chambers are normal, diastolic dysfunction of the left ventricle.
Daily ECG monitoring from 22.07.2011 - single supraventricular and ventricular extrasystole, against the background of persistent horizontal ST-T depression on channel 2 from -0.3 to -0.9 mm, 2 episodes of depression increase to -1.2-1.9 were noted mm at 21:42 and 12:05, lasting 20-30 minutes, without clinical manifestations and connection with physical activity.
MSCT of coronary arteries from 08.2010
The trunk of the LCA is wide, has smooth contours, and is not stenotic. PNA in the proximal segment has irregular contours due to calcified and partially calcified plaques, the lumen of the artery at this level is narrowed up to 30-50%, in the middle segment a number of parietal and circular soft plaques are determined, with artery stenosis up to 60-75%, distal parts of the artery small caliber, poorly filled with contrast agent. OA of normal diameter, filled with a contrast agent without signs of hemodynamically significant stenosis. RCA of normal diameter, in the proximal segment there are mixed partially calcified plaques stenosing the lumen up to 30%, in the middle segment a mixed parietal plaque is visualized, stenosing the lumen up to 50-70%, the distal segment is not changed. Right type of coronary blood supply.
Three-dimensional reconstruction
Oncological search
On June 28, 2011, for the first time, according to CT data of the genitourinary system with intravenous contrast, a CT picture of tumor formation in the right kidney was revealed, with signs of spread to the perinephric tissue and Gerot's fascia. Incomplete doubling of the right kidney. Cysts of both kidneys. Hemangioma of the body L4.
CT scan of the abdominal cavity from 06/08/2011 - CT-picture of the cyst of the left lobe of the liver. CT data on secondary lesions of the abdominal organs were not obtained.
MRI of the small pelvis from 08/08/2011 - MR-signs of involutive changes in the pelvic organs with areas of calcification in the projection of the left ovary. There was no reliable data on the presence of a volumetric formation of the pelvic cavity at the time of the study.
Ultrasound of the mammary glands, mammography from 06/08/2011 - fibrocystic involution of the mammary glands.
CT of the chest organs from 04.08.2011 - CT signs of COPD. Diffuse pneumosclerosis. Interstitial and focal changes in both lungs to differentiate between the phenomena of pneumosclerosis and secondary lesions (taking into account the main diagnosis).
Tactics of further patient management
The patient has absolute indications for surgery for cancer of the right kidney, however, the risk of surgery in conditions of stenosing atherosclerosis of the coronary arteries is extremely high.
At the same time, selective coronary angiography followed by angioplasty and placement of drug-eluting stents would require long-term use of dual antiplatelet therapy (Plavix, acetylsalicylic acid), which would increase the risk of hemorrhagic complications in the context of the upcoming urological surgery and in the postoperative period.
Council of 08/12/2011
The patient has several competing diseases:
1. Determining the prognosis of life is a tumor of the right kidney. Fuzzy changes in both lungs remain unclear, more on the right. The size of the formations does not exceed 5-6 mm; their location, the presence of calcifications and areas of compaction on previous CT scans casts doubt on the metastases of renal cancer.
The patient has frequent exacerbations of chronic obstructive pulmonary disease, therefore, they must be differentiated with areas of fibrosis. It should be borne in mind that even the presence of minimal metastases does not exempt from the need for surgery on the right kidney.
2. An aggravating factor is coronary artery disease with stenosis of the coronary arteries, detected by MSCT of the coronary arteries. Taking into account the fact that during Holter ECG monitoring there is stress-induced myocardial ischemia, then selective coronary angiography is indicated in the near future. If necessary, non-drug-eluting stents will be installed, followed by anticoagulant therapy with heparin and discontinuation of this drug as soon as possible before the next surgical intervention. The choice of this type of stents is due to the possibility of a less intensive regimen of antiplatelet therapy in the conditions of the forthcoming nephrectomy operation, as well as in the postoperative period.
Stationary stage of treatment
The patient was admitted to the hospital clinic "Medicine" on 18.08.2011.
On 18.08.2011, selective coronary angiography was performed.
During the procedure, it was revealed that the trunk of the left coronary artery is usually located. Anterior descending artery - 80% stenosis in the middle third.
The circumflex coronary artery without signs of stenosing atherosclerosis.
Right coronary artery - 70% stenosis in the middle third. Right type of coronary circulation.
Anterior interventricular artery
Right coronary artery
Angioplasty and stenting of coronary arteries
On August 18, 2011, an interventional cardiac surgeon in the area of stenosis of the proximal third of the anterior interventricular artery performed a balloon catheter with a Multi-Link 8 stent measuring 3 × 12 mm, and implantation was performed.
A 0.014 "guidewire was inserted into the distal part of the right coronary artery. A balloon catheter with a Multi-Link 8 stent with dimensions of 3 × 12 mm was placed in the area of stenosis, and implantation was performed.
Control angiograms show good blood flow
In the postoperative period, a continuous infusion of heparin under the control of APTT was carried out, followed by replacement with subcutaneous administration of clexane in therapeutic dosages, followed by withdrawal 12 hours before the next surgical treatment.
Taking into account the complete revascularization of the coronary arteries, the patient was prepared for a planned nephrectomy on the right, and was referred to a urologist for further supervision.
Surgical stage of hospitalization
On August 22, 2011, the patient underwent laparoscopic radical nephrectomy on the right as part of the main hospitalization in the clinic "Medicine".
The postoperative period was uneventful; in the early period, anticoagulant therapy with clexane was carried out in order to prevent thromboembolic complications; continued cardiotropic drugs; prescribed standard antibiotic therapy.
On the second day after surgery, a double antiplatelet therapy was started, including clopidogrel at a dose of 75 mg per day, acetylsalicylic acid at a dose of 100 mg per day.
On the background of complex therapy, the patient became more active, the postoperative wound healed by primary intention; worsening of the course of coronary heart disease was not noted.
The patient was discharged from the hospital in a stable condition on September 7, 2011.
Discharge recommendations:
Bisoprolol 2.5 mg 1 tab. in the morning.
Amlodipine 5 mg ½ tab. in the evening.
Clopidogrel 75 mg, 1 tab. in the morning.
Acetylsalicylic acid 100 mg 1 tab. in the evening.
Atorvastatin 20 mg in the evening.
Rabeprazole 20 mg, 1 tab. in the morning.
Clinical diagnosis
Coronary heart disease. Functional class II exertional angina. Atherosclerosis of the coronary arteries. Angioplasty and stenting of the anterior descending artery with a non-drug-eluting stent "Multi-Link 8" measuring 3 × 12 mm. Angioplasty and stenting of the right coronary artery with a non-drug-eluting stent "Multi-Link 8" measuring 3 × 12 mm from 18.08.2011 Hypertension stage III. Arterial hypertension II degree. Dyslipidemia II A type. MTR risk 4.
Hypertensive nephropathy. Chronic kidney disease stage 3B (glomerular filtration rate according to CKD-EPI 38.2 ml / min / 1.73 m 2 ).
Violation of the rhythm of the heart: ventricular and supraventricular extrasystole. Stage I circulatory insufficiency.
Cancer of the right kidney T1N0M0G1. Laparoscopic nephrectomy on the right from 22.08.2011. Chronic pyelonephritis, remission stage.
Features of the clinical case
A feature of the management tactics for this patient was the continuity between interventional methods of treatment of stenosing atherosclerosis of the coronary arteries and the performed right-sided nephrectomy for cancer within the same hospitalization.