Abstract

Coronary artery disease (CAD) primarily occurs in patients over the age of 40 and is known to be the main cause of
morbidity and mortality in patients with diabetes mellitus. Although they do not often show typical recognized
symptoms, diabetic patients suffer from more extensive CAD and hence higher incidence of multi-vessel CAD than
in non-diabetic subjects. Literature has given the strength of evidence in favor of surgical revascularization in
diabetic patients with multi-vessel disease. We report the case of a 66-year old active smoker and diabetic man with
a symptom of light shortness of breath with no chest pain. The coronary angiography revealed a severe three-vessel
disease and left main disease with light mitral valve regurgitation. The heart team decided to do a percutaneous
coronary intervention was successfully performed with intra-aortic balloon counterpulsation at LMM-LAD, as the
patient refused to follow heart team indication to undergo coronary bypass grafting. In this article we will describe a
rare case of successful stenting in 3 vessel disease case involving the left main artery.

Introduction
Coronary artery disease (CAD) and its complications such as myocardial infarction or heart failure is one of the
leading causes of death in most world populations.1,2 Three vessel disease (3VD) represents the most severe form
of coronary atherosclerosis. Patients with 3VD and /or left main stenosis are considered a high risk group according
to therapeutic guideline.3 The perceivable link between the coronary artery disease (CAD) and diabetes mellitus had
been known for many years. The incidence of coronary artery disease (CAD) in diabetics is four times higher
compared to the age-adjusted general population.4 Furthermore,CADis known to be the main cause of morbidity
and mortality in patients with diabetes mellitus (DM).5 Although they do not often show typical recognized
symptoms, diabetic patients suffer from more extensive CAD and hence higher incidence of multi-vessel CAD than
in non-diabetic subjects.6 Multi-vessel coronary artery disease revascularization is commonly performed throughout
the world. Among approximately 700,000 patients who undergo multivessel coronary revascularization yearly, 25%
have diabetes.5,7 For the last two decades, there has been intense debate between interventional cardiologists and
surgeons regarding the most effective mode of revascularization in patients with diabetes, particularly in those with
multivessel disease or left main stenosis, until the FREEDOM trial gave the strength of evidence in favor of
coronary artery bypass grafting (CABG).8-12 However, surgical revascularization is not always feasible or accepted
by all the patients. Otherwise, although single-center observational data had suggested a reduction in mortality and
major complications with the use of an elective intra-aortic balloon pump (IABP) during high-risk PCI,13-14 the
first randomized controlled evaluation of the safety and efficacy of counterpulsation during high-risk PCI did not
confirm these findings.15

Case Report
A 66 year old man who actively smoking (2 pack per day since 40 years ago) with a history of non-insulin
dependent diabetes mellitus for the past 5 years treated daily by 2 tablets of metformin and gliclazide 60 mg once
daily as well as history of hypertension for the past 12 years treated by 1 tablet daily of amlodipine 5 mg, come to
the hospital for medical care due to shortness of breath for the past 2 days. Clinical physical examination was
normal. Blood test result revealed an increased cardiac enzyme of Troponin I (firstly checked was 404 and 12 hours
later it became 761). In the baseline 12-lead electrocardiogram showed a ST depression of 3-4 mm at lead V3-V5.
Trans-thoracic echocardiography found an impaired left ventricular function (ejection fraction 34%) with mild
Mitral Regurgitation and mild Tricuspid Regurgitation. A coronary angiography was performed : left angiogram
revealed calcifieddistal left main stenosis associated with proximal to middle Left Anterior Descending (LAD) and a
stenosis of proximal segment Left Circumflex (LCX); while right coronary angiogram showed a totally occlusion at
the proximal of RCA.

References
1. Gersh BJ, Sliwa K, Mayosi BM, Yusuf S. Novel therapeutic concepts: the epidemic of cardiovascular
disease in the developing world : global implications. Eur Heart J 2010; 31:642-648
2. WHO. World Health Organization – Global atlas on CVD prevention and control. 2011; Available from :
http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf (accessed 15/06/2018)
3. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous
coronary intervention in patients with three vessel disease and left main coronary disease:5-year follow-up
of the randomized, clinical SYNTAX trial. Lancet 2013; 381:629-638
4. Nazimek-Siewniak B, Moczulski D, Grzeszczak W, et al. Risk of macrovascular and microvascular
complications in Type 2 diabetes: results of longitudinal study design. J Diabetes Complication
2002;16(4):271–6.
5. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics-2012 update: a report from the
American Heart Association. Circulation 2012;125:2–220.
6. Waller BF, Palumbo PJ, Lie JT, Roberts WC. Status of the coronary arteries at necropsy in diabetes mellitus
with onset after age 30 years. Analysis of 229 diabetic patients with and without clinical evidence of
coronary heart disease and comparison to 183 control subjects. Am J Med 1980;69(4):498–506.
7. Smith SC, Faxon D, Cascio W, et al. Prevention Conference VI:Diabetes and Cardiovascular Disease:
Writing Group VI: revascularization in diabetic patients. Circulation 2002;105:165–9.
8. Tamburino C, Angiolillo DJ, Capranzano P, et al. Complete versus incomplete revascularization in patients
with multivessel disease undergoing percutaneous coronary intervention with drug-eluting stents. Catheter
Cardiovasc Interv 2008;72(4):448–56.
9. Tamburino C, Angiolillo DJ, Capranzano P, et al. Long-term clinical outcomes after drug-eluting stent
implantation in unprotected left main coronary artery disease. Catheter Cardiovascular Intervention
2009;73(3):291-8.
10. Galassi AR, Colombo A, Buchbinder M, et al. Long-term outcomes of bifurcation lesions after implantation
of drug-eluting stents with the ‘‘mini-crush technique’’. Catheter Cardiovasc Interv\ 2007;69(7):976–83,
Jun 1.
11. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Comparison of coronary
bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996;335:217–25.
12. Farkouh ME, Domanski M, Sleeper LA, et al. FREEDOM Trial Investigators. Strategies for multivessel
revascularization in patients with diabetes. N Engl J Med 2012;367:2375–84.
13. Briguori C, Sarais C, Pagnotta P, et al. Elective versus provisional intra-aortic balloon pumping in high-risk
percutaneous transluminal coronary angioplasty. Am Heart J. 2003;145:700–7.
14. Mishra S, Chu WW, Torguson R, et al. Role of prophylactic intra-aortic balloon pump in high-risk patients
undergoing percutaneous coronary intervention. Am J Cardiol 2006;98:608–12.
15. Perera D, Stables R, Thomas M, et al. Elective intra-aortic balloon counterpulsation during high-risk
percutaneous coronary intervention: a randomized controlled trial. JAMA 2010;304: 867–74.