#percutaneous

Abstract

Endovascular Aneurysm Repair (EVAR) is a routinely used minimally-invasive treatment technique for Abdominal Aortic Aneurysm (AAA). Trans catheter Aortic Valve Implantation (TAVI) is widely accepted as an alternative to surgical valve replacement in elderly or high risk patients with aortic stenosis. Aortic aneurysm and aortic stenosis may coexist in an older age group often with other comorbidities. Combined procedures increase complexity and are thought to increase morbidity and mortality compared to sequential procedures. However in some circumstances the risk of a combined TAVI and EVAR may reduce cumulative risk compared to sequential procedures [1]. We describe the case of a 79 years old male patient with incidental findings of asymptomatic AAA and severe Aortic Stenosis (AS) who underwent successful simultaneous TAVI and EVAR under local anesthesia.

Keywords: TAVI; EVAR; Percutaneous; Local Anesthesia

Case Presentation

A 79-year-old male was referred to our tertiary unit due to an incidental finding of a pulsatile abdominal mass. He was an ex-smoker with a previous history of transient ischemic attack and left carotid endarterectomy. Co-morbidities included Type II diabetes mellitus and previous asbestos exposure. Computed Tomogram (CT) angiography showed an 8.4 cm infra-renal aortic aneurysm with a narrow (18mm) and angulated (73 degrees) neck (Figure 1). CT also showed extensive arteriosclerosis involving the coronary arteries, abdominal aorta, both iliac and femoral arteries.

Echocardiogram performed to assess fitness for AAA repair, revealed severe aortic valve stenosis (Aortic Valve Vmax=4.3cm/s, indexed orifice area <0.8cmsq), moderate LV impairment with moderate mitral regurgitation. Gated Cardiac CT showed heavily calcified tri-leaflet aortic valve. Invasive coronary angiography revealed complex 3-vessel Coronary Artery Disease (CAD). A multidisciplinary team comprising of operating vascular radiologist, cardiologist, vascular and cardiac surgeon and vascular anesthetist, concluded that the patient would be high risk for open cardiac surgery with impaired LV function, previous TIA and risk of intra-operative aneurysmal rupture. Therefore, TAVI was offered as the preferred treatment for the aortic stenosis and EVAR for the AAA.

Given the potential need for future intervention for coronary artery disease, an intra-annular sub-coronary TAVI device (Edwards Sapien 3-Edwards Life sciences Corp, Irvine, USA) was selected. This requires trans femoral access for implantation. There was concern that the required trans-femoral approach carried a risk of peri-operative aneurysm rupture. In addition, the newer valve delivery device with dynamic expansion mechanism would reach an equivalent of 24 French inner diameter post deployment which is a larger diameter than the 22 French device required to deliver the EVAR. A simultaneous TAVI and EVAR would avoid a re-puncture of the femoral artery with attendant operative risks for the patient. Therefore, a plan was formulated to undertake the TAVI under local anesthesia and if this was well tolerated to proceed with the EVAR immediately afterwards. Conversion to general anesthesia for the EVAR could be performed at that stage if necessary. Due to the narrow and angulated neck, an Aorfix device (Lombard Medical, Oxford, UK) was selected for the EVAR.

In a vascular hybrid suite, the patient was prepared and draped including access for an open surgical AAA repair if needed. Under local anesthesia, percutaneous vascular access was obtained, of bilateral femoral arteries and left brachial artery. A left femoral venous access was obtained for Temporary Pacing Wire (TPW) insertion. TAVI was performed in standard retrograde fashion; systemic heparinization (5000 IU) and balloon aortic valvuloplasty during rapid pacing (Figure 2). A balloon mounted Edwards Sapien 3 aortic valve was crimped on table and deployed successfully. There was trivial aortic regurgitation and a new left bundle branch block was noted with no further sequela. Hemodynamic benefit was immediate with reduction of trans-aortic gradient and reduction in left ventricular end diastolic pressure. Given a stable patient, the EVAR procedure was commenced (Figure 3a) under LA. Using fluoroscopic guidance, a bifurcated infrarenal abdominal aortic stent graft (Aorfix - Lombard) was deployed (Figure 3b). The main body was fixed and moulded to follow the neck angle. Procedure was completed with the limbs of the stent graft extended down to the iliac bifurcation bilaterally. The femoral arteriotomies were closed with prepositioned sutures (Pro Glide; Abbott Vascular, Santa Clara, CA, USA). There were no immediate post-operative complications.

The total procedure time was 160 min, the total fluoroscopic time was 80 min, and the amount of iodinated contrast medium (Visipaque 300 GE Amersham) used was 200 ml. The TPW was left in-situ for 24 hours and patient monitored on the coronary care unit for 24hours and then stepped down to a standard ward. The patient made an uneventful recovery and was discharged home from hospital on the second post-operative day.

Discussion

Abdominal aortic aneurysm is a relatively common condition among elderly men with reported prevalence of 4.9% in the UK [2]. Large aneurysms have a natural history of progressive enlargement that can lead to rupture with a risk as high as 6.5% per year, in patients with aneurysmal diameter greater than 5cm [3,4]. Open surgical repair is generally associated with significant morbidity and mortality in the elderly population due to their multiple comorbidities as in the index patient. Increasing evidences showing EVAR has reduced short term operative mortality when compared to open surgery and has led to rising preference for EVAR in management of patients with AAA [5,6].

The Aorfix stent graft used in this case is a modular device composed of a circular ring body and helical limb nitinol frame covered by a woven polyester fabric [7]. It is extremely flexible and readily compliant with narrow tortuous vessels and several multicenter studies have demonstrated its utility in AAA patients unsuitable for repair with other available commercial grafts with Aorfix giving technical success as high as 96% [7].

In our institution TAVI procedures are usually performed via the Left Subclavian Artery (LSCA) with self-expanding valves in patients with poor femoral access or infra-aortic aneurysm. Trans-subclavian access for TAVI is usually an excellent alternative approach and in a prospective study showed lower rates of vascular complications at sheath insertion site and all bleeding events related to vascular complications. Subclavian access also reported a lower rate of acute kidney injury. Similar rates were observed for procedural success, major vascular complications and life-threatening bleeding events [8]. However in this case we preferred a Trans Femoral (TF) sub-coronary valve, allowing easier access if future coronary intervention were required. The LSCA approach was also felt to be unsuitable with concerns of the angulation affecting our ability to mount the valve on the balloon in-vivo. The LSCA approach is also ‘off-label’ and not recommended by device manufacturer.

After careful consideration and discussion with the patient we opted to perform both procedures under Local Anesthesia (LA) rather than General Anesthesia (GA). LA is known to improve safety and patient haemodynamic stability whilst reducing post-operative recovery, length of stay and pulmonary morbidity when compared to GA in patients undergoing either TAVI or EVAR procedures. As TF TAVI would involve traversing the angulated aneurysm with a 24 French sheath, this could be easily used to deploy the Aorfix EVAR main body. It was also felt the groin would be more hostile for an EVAR access later. More importantly the improved cardiac output post TAVI would increase the risk of rupture of the 8.3cm AAA.

We chose Local Anesthesia (LA) over General Anesthesia (GA) because of the known improved safety, simplicity, more stable patient hemodynamics, shorter post-operative recovery period, length of stay in high dependency units and reduction in pulmonary morbidity when compared to GA in patients who have undergone either TAVI and EVAR procedures [9]. While there is paucity of data on large scale studies of similar combined procedures, available reports suggests combined TAVI and EVAR procedures can reduce the risks associated with the perioperative period when compared to sequential procedures thereby improving post-operative mortality and morbidity [1]. As this was our first combined TAVI and EVAR, several precautionary steps were included, which may become less necessary with experience, reducing procedural time. Use of medical carbon dioxide as contrast agent for EVAR can decrease the iodinated contrast load especially in straight neck AAA. The Edward Sapiene Sheath with dynamic expansion mechanism required exchanging to a standard 24Fr sheath as its stiff bleed back prevention valve did not provide adequate seal to undertake EVAR. This case suggests that simultaneous TAVI and EVAR using a femoral approach under local anesthetic is feasible and may be considered. Given the complexity of the procedures and the numbers of personnel involved, clear communications and detailed planning between team members is essential for a successful outcome.

Acknowledgement

We would like to acknowledge Dr. Daniel Blackman, Dr. Michael Cross, Dr. Jeevan Mahaveer, Mr. Tom Wallace, Mrs. Anneke Winter (Aorfix Lombard proctor), Cardiac intervention, vascular intervention, vascular surgery and anesthetic support staff who helped and supported the case.

Compliance with Ethical Standards

On behalf of all authors, the corresponding author states that there is no conflict of interest. Authors declare no relationship with industry. The paper is not under consideration elsewhere; the paper's contents have been previously published and all authors have read and approved the manuscript. For this type of study formal consent is not required. Informed consent was obtained from all individual participants included in the study.

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Abstract

Introduction: Percutaneous Cholecystostomy (PC) is a radiological intervention used in the management of high risk or critically ill patients with acute cholecystitis (AC)

Method: A retrospective study of outcomes following PC, including success rates, rates of res-olution of AC, complication rates, readmissions rates, post-procedure endoscopic retrograde cholangiopancreatography (ERCP) rates and rates of subsequent cholecystectomy.

Results: Our database identified 28 patients (14M;14F), median age 73 (range 40-93). 82% were ASA III/IV. Median follow-up was 2 (range 0-8) years. Imaging suggested AC in 61% and empyema in 39%. 86% were calculous. All procedures were USS-guided with 100% success. Resolution of AC occurred in 89.3%. Of three unresolved, there was 1 death day-1 post-PC (non-procedure related), 1 index cholecystectomy, 1 chronic complicated cholecystitis. 28.6% devel-oped complications, 2 major (1 late biliary peritonitis with subphrenic abscess, and 1 cholecys-to-cutaneous fistula with abdominal wall abscess), 17.9% had dislodged drains, and 14.3% had other minor complications. 20 (71.4%) patients had bile cultures taken, of which 60% were posi-tive. 17.9% patients were readmitted with AC, 1 had repeat PC. 21.4% had subsequent ERCP. 32.1% underwent subsequent cholecystectomy, of which there was 1 laparoscopic cholecystec-tomy (LC) index, 4 elective (3 LC, 1 open) and 4 emergencies (2 LC, 1 LC subtotal, 1 failed open with drain insertion). There were no procedure related mortalities although 39.3% patients died during the follow-up period, a reflection of their pre-existing multi-morbidity.

Conclusion: PC is both safe and effective with significant procedural success rates and resolu-tion rates. There are few major complications but significant morbidities including high rates of dislodged drains. There is a high readmission rate with further biliary disease and high rates of subsequent choledocholithiasis requiring subsequent ERCP. Only one-third of patients have subsequent cholecystectomy. Further RCTs are required to determine whether PC or LC is a su-perior option in high-risk patients.

Background and Indications

Gallstone (GS) related diseases, of which AC is the most common, are some of the most fre-quently encountered acute surgical emergencies. 10-15% of the adult population in developed countries is affected by gallstones, with 20% of symptomatic patients presenting as AC [1]. The incidence of gallstone disease increases with age [2], as do co-morbidities, making management of AC challenging.

AC can be calculous (approximately 90% cases) or acalculous. Acute Calculous Cholecystitis (ACC) results from gallstone impaction either at the neck of the gallbladder (GB) or in the cystic duct. This results in obstruction to the outflow of bile, with subsequent distension, oedema and inflammation of the GB wall. If the obstruction persists, bacterial superinfection occurs leading to AC, which can progress to empyema. Ischaemia and necrosis can also supervene, leading to a gangrenous GB. Subsequent perforation can lead to localized abscess formation or even peri-tonitis. Patients may become critically ill from sepsis and its sequelae if left untreated. Acute acalculous cholecystitis (AAC) occurs in absence of GS. It occurs in the critically ill and is thought to be related to either bile stasis or ischaemia of the GB.

Laparoscopic cholecystectomy (LC) under general anaesthetic is the standard treatment of ACC and is performed in the early acute phase of the disease, in patients fit to undergo the proce-dure. However, in high-risk critically ill patients where operative intervention poses a significant mortality risk, PC has an established role. PC can be used with two intentions. Firstly, it is most commonly used as a bridge or temporizing measure in AC, allowing elective planned cholecystectomy when the patient is more stable. Secondly, it can be used as a definitive treatment in multi-morbid patients who are unfit for surgery. Thirdly, in patients with AAC, it is the definitive procedure.

The Tokyo Guidelines recommend appropriate intervention for different grades of AC (see Table 1) [3].  The severity of inflammation of the GB is associated with the difficulty of LC and carries in-creased risks of bile leak, common bile duct injury or conversion to an open procedure, espe-cially if LC is performed for severe AC beyond one week after the onset of symptoms. Grade I ACC (mild) is associated with no organ dysfunction and limited disease in the gallbladder, grade II (moderate) is associated with no organ dysfunction but extensive inflammatory gallbladder disease, making cholecystectomy difficult, whilst Grade III is associated with organ failure. Grade I patients are candidates for early LC; grade II patients could have either LC or PC (also called percutaneous transhepatic gallbladder drainage - PTGBD); immediate PC/PTGBD is strongly recommended for grade III patients.

The Technique

PC was initially described in 1867 but was first performed under USS guidance in 1980. It is a minimally invasive radiological procedure that involves placement of a drainage catheter into the lumen of the GB, under aseptic conditions. It is performed under image guidance via either the trocar or modified Seldinger technique. Indications of PC include calculous or acalculous cholecystitis, cholangitis, and biliary obstruction. The majority of patients undergoing PC are generally unfit for a cholecystectomy at initial presentation (Figure 1) [4].

There are 2 approaches, trans-hepatic and trans-peritoneal, each with its own advantages and disadvantages.  With the trans-hepatic route the catheter is passed through the liver (extra-peritoneal) into the gallbladder. This theoretically not only reduces the risk of bile peritonitis but gives greater stability to the catheter. If the gallbladder is significantly distended, the trans-peritoneal route becomes more feasible. Since the trans-peritoneal approach carries the risk of bile peritonitis however, the trans-hepatic route is generally preferred (Figure 2). Ultrasound-guided cholecystostomy with an 8-French drainage catheter (white arrow) placed into the gallbladder using the trocar tech-nique (same patient with Figure 1). White asterisk indicates posterior acoustic shadowing from gallstones [5].

There are usually no absolute contraindications to PC, but relative contraindications include co-agulopathy (needs correction), ascites, GB full of stones preventing access, and GB tumor. Complications associated with PC either are immediate or can occur within days. These include haemorrhage, bile leak/bile peritonitis, pneumothorax, bowel perforation (usually via the trans-peritoneal route), colonization of the GB, infection/abscesses and catheter displace-ment/migration (most common).

AIM

The main aim of this study was to evaluate outcomes following PC at our Health Board. Primary outcomes were success rates, rate of resolution of AC, complications, readmission rates and subsequent cholecystectomy performed. Secondary outcomes were bile cultures, repeat proce-dures and other procedures performed.

Methods

A total of 28 patients were identified on WelshPAS (Digital Patient Record System) as having undergone PC between 2011 and August 2020. Patient data was extracted for retrospective analysis using Welsh Clinical Portal and patient medical notes. Data collected included patient demographics, ASA grades, calculous vs acalculous cholecystitis, procedural success rates, reso-lution rates, complications, bile cultures taken (and organisms cultured), re-admissions rates, further procedures and subsequent cholecystectomy.

Results

The database identified 28 patients (14 male and 14 female) with an age range of 40 to 93 years (median age 73). 82% of patients were of an ASA grade of III or IV (18 patients grade III, 5 patients grade IV). The median patient follow-up was 2 years (ranging from 0 - 8 years). Ultra-sound and/or CT imaging indicated severe AC in 61% of patients (with 86% being calculous) and AC with associated empyema in 39% of patients (Table 2).

All cholecystostomies were ultrasound-guided with a 100% success rate. Resolution of acute cholecystitis occurred in 25 (89.3%) patients. Of the three unresolved patients, there was one chronic complicated cholecystitis, one index cholecystectomy and one death day-1 post chole-cystostomy (due to a cardiac cause). 28.6% of patients developed complications due to the PC, some of whom had more than one complication. Two major complications included one late biliary peritonitis (including subphrenic abscess), and one cholecysto-cutaneous fistula with abdominal wall abscess. Both these patients had sur-gical intervention and recovered [5]. (17.9%) patients had dislodged drains (with one patient re-quiring a repeat procedure within 1 week), whilst 3 other complications were blocked drain, excessive granulation of drain site and abdominal wall cellulitis (Table 3).

20 (71.4%) patients had bile cultures taken, with 70% of these being positive. Gram-negative organisms were cultured in 8 patients (mainly coliform) whilst gram-positive organisms (3 En-terococcus, 1 Aerococus, 1 Streptococcus viridans) were cultured in 7 patients (Table 4).  17.9% of patients were readmitted with further acute cholecystitis, with one patient having a repeat PC one week after the primary procedure, and another patient having a second PC pro-cedure 2 years after the first. 21.4% of patients had subsequent endoscopic retrograde cholan-gio-pancreatography (ERCP).  32.1% of patients underwent subsequent cholecystectomy. Of these, one was an index procedure, four were elective procedures (3 laparoscopic, 1 open), and four were emergency procedures (2 laparoscopic, 1 laparoscopic subtotal, and one failed open with open cholecystostomy tube drain inserted) (Table 5 & 6). While there were no procedure-related mortalities, 11 patients (39.3%) died during the follow-up period due to pre-existing morbidities as reflected by their ASA classifications.

Discussion

PC is a minimally invasive procedure that can be lifesaving for patients who are critically ill from severe AC. PC leads to resolution of AC in most cases, with high success rates and minimal mortality. It is reliable, cost effective and can be easily performed. There are associated significant morbidities however, and it does not deal with the primary source of the problem, which is gallstones.

A systematic review conducted by Winbladh et al in 2007 [6]  analysed the safety and efficacy of PC in elderly and critically ill patients. It reported a success rate of 91% in patients with con-firmed ACC and a procedure related mortality of 0.4%. The overall complication rate was low (6.2%). Our overall complication rate was much higher than this (28.6% of patients), although the majority of these were minor complications.

Bundy et al reported technical success and resolution rates of 100% [7]. Other studies report reso-lution rates of around 90%. Our study had similar outcomes. Furtado et al showed a 29% rate of subsequent cholecystectomy, [8] similar to our study.  The study also found that although PC was a life-saving procedure, there was significant associated morbidity, with 44% rate of choledocho-lithiasis, 27% rate tube dislodgment, and 23% rate postoperative abscess.  Our results were also comparable to this.

There have been few RCTs comparing PC to emergency cholecystectomy (EC). A multi-centre RCT Netherlands [9] very interestingly showed LC as superior to PC drainage in treatment of high-risk patients with ACC. It demonstrated no difference in mortality between LC and PC (3% vs 9%, P=0.27) in high-risk patients with ACC. However, LC had a significantly lower major compli-cation rate than PC (12% vs 65%, P<0.001). Recurrent biliary disease occurred more often in the PC group compared to the LC group (53% vs 5%, P<0.001). In this RCT, LC not only reduced rate of major complications but also need for re-intervention for recurrent biliary disease.

Our study failed to correlate with the high mortality rate for PC in severe disease compared to the RCT, although we do acknowledge that our study was limited by low patient numbers. Our rate of major complications was also significantly lower that in this study. However, our study did show significant rates of readmissions with biliary disease as well as a high rate of chole-docholithiasis requiring ERCP.

A study by Schlottmann et al in 2018 [10] used a retrospective population base analysis of over 200,000 elderly patients (7516 PC vs 193,399 cholecystectomy). This study showed that there was a higher incidence of post-procedural morbidity and mortality in the PC group compared to the cholecystectomy group and concluded that elderly patients with AC should undergo chole-cystectomy. However, in 2011 Melloul et al [11] found that although PC and EC were both effective in the resolution of AAC sepsis, EC was associated with a higher procedure-related mortality and conversion rate and concluded that PC remains a valuable intervention.

There were some obvious limitations with our study, such as low patient numbers even though this represented a ten-year review. Additionally, patients were not necessarily graded as per Tokyo Guidelines for severity since the study period pre-dates the publication of the guidelines. As most patients were ASA III/IV, we presume they all fell into AAC grades II and III.

Conclusion

Our study demonstrated that PC is both safe and effective in the treatment of severe acute cholecystitis. PC was associated with a high procedural success rate and high-resolution rate, with no procedure related mortalities. There were few major complications, however a significant rate of overall complications. We found PC to be associated with significant readmission rates with further biliary disease and high rates of choledocoholithiasis requiring subsequent ERCP. Only one third of patients had subsequent cholecystectomy. In view of significant overall complication rates and recurrent biliary disease, further RCTs need to be conducted in order to determine whether LC or PC is a superior intervention in these high-risk patients. PC, however, remains an invaluable treatment option.

Percutaneous Vertebroplasty, also known as vertebral packing or vertebroplasty, is a procedure in which a medical grade cement is injected through a needle into a painful, fractured vertebral body. The procedure is aimed at preventing vertebral body collapse and pain in patients with bone failure. The procedure originated in the year 1984 has become popular, and many technical improvements have been made since then.

Indications

Severe painful osteoporosis with loss of height or compression fractures of vertebral bodies.

Painful compression fractures in patients with osteoporosis refractory to conservative therapy.

The ideal candidate for vertebroplasty presents within four months of fracture and has midline, nonradiating back pain that increases with weight-bearing and can be exacerbated by manual palpation of the spinous process of the involved vertebra.

Symptomatic vertebral angioma.

Painful vertebral body tumors and acetabular tumors.

In cancer patients, the technique is used mainly in the symptomatic treatment of osteolytic bone metastases and myeloma. As vertebroplasty is intended only to relieve pain weight-bearing bone, other specific tumor therapy should be given in conjunction.

The use of PMMA is reserved for the weight-bearing bone. In other locations, alcohol or other pain thermoablation techniques can be used to treat the pain.

Contraindications

Hemorrhagic diathesis

Infection

Lesions with epidural extension. These require a careful injection to prevent epidural overflow and spinal cord compression by the cement or displaced epidural tissue.

Patients with more than five or diffuse metastases

Overview of the procedure

The procedure is performed under local anesthesia combined with neuroleptanalgesia. The patient is placed in a prone position for lumbar and thoracic levels and supine position for cervical levels.

A 15-gauge needle is used for cervical vertebrae and a 10-gauge needle for thoracic and lumbar vertebrae. A dual-guidance CT and C-arm fluoroscopy or biplane fluoroscopy is used.

CT is used to determine the entry point and the pathway, avoiding the nerve root and visceral structures. The needle is safely guided under CT or biplane fluoroscopy.

The imaging mode is switched to fluoroscopy once the needle is held in the optimal position.

The acrylic cement mixed with tantalum (to increase radiopacity) is injected during the pasty polymerization phase to prevent distal venous migration.

The injection of cement is carefully controlled under strict lateral fluoroscopy. The injection is stopped when epidural or paravertebral opacification is observed or when the cement reaches the dorsal quarter of the vertebral body.

Complications

Cement leak is the most severe and frequent complication.

The second most serious complication is an infection.

Temporary pain might occur after the procedure.

Allergic reactions and hypertension are limited in these procedures as the quantity of cement injected in this procedure are far less than that used in orthopedic surgery.

Contemporary Percutaneous Coronary Intervention for Patients with Acute Myocardial Infarction and Left Main Culprit Lesions: A Report from the NCDR® by William B Hillegass in Open Journal of Cardiology & Heart Diseases

Background: The characteristics and in-hospital outcomes of PCI for LM AMI have not been studied in a large patient population

Objectives: To describe the incidence, characteristics, in-hospital outcomes and prognostic determinants of percutaneous coronary interventions (PCI) for acute myocardial infarction (AMI) due to unprotected left main coronary artery UPLMCA lesions.

Methods: The characteristics and in-hospital outcomes of PCI for LM AMI were studied in the CathPCI Registry® between 2004 and 2008.

Results: 434 patients underwent PCI for ST elevation MI (STEMI) and 387 patients underwent PCI for Non STEMI due UPLMCA lesions. Cardiogenic shock and class 4 NYHA were present in 66.4% and 74.9% of patients with STEMI respectively compared with 31.9% and 51.7% of patients with NSTEMI. The in-hospital mortality rate was 58% in the UPLMCA STEMI patients and 28% in the UPLMCA NSTEMI patients compared to 19% in a cohort of 116 patients with protected LMCA (PLMCA) STEMI and 6% in a cohort of 610 patients with PLMCA NSTEMI PCIs. Significant variables associated with in-hospital mortality were age/10 years increase (odds ratio [OR]=1.2; 95% confidence interval [CI]: 1.02-1.4), primary PCI (OR=0.6; CI: 0.4-0.97), GFR/10 unit increase (0R=0.9; CI: 0.8-0.97), UPLMCA NSTEMI (OR=2.6; CI: 1.5-4.2), UPLMCA STEMI (0R=5.0; CI: 3.0-8.4), cardiogenic shock (OR=7.5; CI: 5.2-10.8), pre PCI IABP placement (OR=2.3; CI: 1.1-4.7), salvage PCI (OR=4.3; CI: 2.3-8.1), and pre PCI TIMI flow 0/1 (OR=2.3; CI: 1.6-3.3).

Conclusion: PCI for UPLMCA AMI carries a very high in-hospital mortality rate, particularly in patients presenting with STEMI and cardiogenic shock.