Wednesday Morning Live Cases Involve Audience in Clinical Challenges

The live cases of ISET 2019 continued on Wednesday morning with two teams from Miami Cardiac &Vascular and one from Ballad Health System. The first live case of the morning was broadcast from Miami Cardiac & Vascular and involved a 54-year-old HIV-positive man with Rutherford III claudication. The patient also had hyperlipidemia and a history of smoking.

Operator Constantino Pena, MD, said he thought the case details were interesting and raised the question of how to approach the external iliac region. Ripal Gandhi, MD, also operating on the case, described progress thus far and the challenges involved in access. Moderator Barry T. Katzen, MD, polled the audience on their preferred access for this particular external iliac lesion and found that 67% preferred ipsilateral left, 27% preferred right to left, 0% preferred brachial, and 6% preferred radial. The operators also decided to choose ipsilateral left.

Another Miami case was led by James Benenati, MD. Dr. Benenati’s team presented a 68-year-old man with left arm numbness and coldness secondary to arterial insufficiency due to left subclavian artery stenosis. The patient did not have subclavian steal syndrome, the operators noted.

After describing imaging and other case details, the panel and operators discussed the possibility of going through the wrist but ruled it out due to poor flow, physical findings, and other reasons.

A panel member asked if use of a distal protection device was considered. Dr. Benenati confirmed the team had considered that possibility but opted against it after extensive discussion.

Dr. Katzen commented, “I think the audience is seeing the benefit of team think, team approach in discussing all these options and getting everybody involved in these complex cases.”

The moderator then directed the audience’s attention to another case, this one from Ballad Health System and led by Chris Metzger, MD. The patient was a 76-year-old man with CAD, PCIs, and LVEF 30%. He had hypertension, dyslipidemia, mild short-term memory issues, and a prior bicycle accident that he left him with a neck injury and limited mobility.

Additionally, the patient had experienced significant difficulties with anesthesia on several past occasions. He had a history of 2 episodes of right hemispheric TIAs, and he presented with severe symptomatic right internal carotid artery stenosis. There was a significant component of soft plaque in the area of the symptomatic stenosis, Dr. Metzger added.

Operators and the panel discussed the appropriateness of placing a stent in this patient, and the audience was polled. Poll results indicated that 91% of the audience thought this was an ideal carotid stent patient, and Dr. Metzger agreed.

After much discussion and observation of all cases, Dr. Katzen thanked the operating teams for their time and congratulated them on great cases.

—Lauren LeBano