38 year old male is a case of ESRD due to diabetic nephropathy. He is on maintenance hemodialysis. He was advised renal transplant. He has severe anemia (Hb 6 gm%) and hypertension due to ESRD.

He gave history of exertional dyspnoea class II of 3 months duration. ECG showed LBBB. Echo showed mild concentric LVH, no RWMA and good LV function.

His coronary angiogram is shown below.

The first film is an RAO caudal view showing tight ostial stenosis of dominant LCx. The second film is an LAO cranial view showing 50% proximal LAD stenosis.

His stress myocardial perfusion image is shown below.

This shows mild reversible perfusion defect in the septum. This may be due to coronary disease or it may be an LBBB artifact.

The dilemma in this case is-

ESRD patient needs renal transplant. Has tight ostial stenosis of dominant LCx. No angina. SPECT inconclusive. What to do?

  • Renal transplant directly
  • CABG followed by renal tranplant
  • PCI followed by renal tranplant

 

Let us examine the ACC AHA criteria for coronary revasularization-

 

Revascularization is not indicated (class III) in the following situations-

  • 1. Use of PCI or CABG for patients with one– or two vessel CAD without significant proximal LAD CAD, who have mild symptoms that are unlikely due to myocardial ischemia, or who have not received an adequate trial of medical therapy and
    • a. have only a small area of viable myocardium or
    • b. have no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)
  • 2. Use of PCI or CABG for patients with borderline coronary stenoses (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)
  • 3. Use of PCI or CABG for patients with insignificant coronary stenosis (less than 50% diameter). (Level of Evidence: C)
  • 4. Use of PCI in patients with significant left main coronary artery disease who are candidates for CABG. (Level of Evidence: B)

The parts in the class III recommendation that are relevant in the present situation are underlined.

Thus in this patient with single vessel disease that does not involve significant proximal LAD disease with mild dyspnoea which is most likely a part of the fluid overload state of ESRD than due to coronary ischemia and with only a small area of involved myocardium, revascularization is not indicated.