Recent PCI, tongue cancer

Gabrielle Morris

Incidental finding of PET-avid lesion at base of tongue, thought likely to be cancer. PET scan arranged due to incidental finding of RLL lesion during CTPA (RLL lesion not PET-avid, non-concerning)

Background

  • IHD – recent angina (not ACS), 90% LAD lesion 2 x stents placed 2/7 ago. Surgery planned in 1wk. Symptoms now resolved.
  • Indigenous
  • Ex-heavy smoker
  • HTN
  • ? OSA – high STOPBANG but low ESS
  • High BMI
  • Ex-tol > 4 METS

Issues

  • Surgery timing
    • Usually the minimum time frame between PCI and surgery is 1/12 (based on most recent evidence J Am Coll Cardiol 2016;68:2622–32) however even this cardiologist dependent. Other relevant factors – stent location, number, caliber, overlaps, branching. 
    • See attached article
    • Discussions documented between surgical and cardiology teams suggest that everyone is in agreement with a plan for surgery and cessation of DAPT for 7d prior.

Discussion

  • Patient at high risk of stent thrombosis if surgery proceeds now.
  • Availability of emergency PCI on site is ideal, however being an LAD lesion, stent thrombosis may be fatal due to large myocardial territory at risk. 
  • could aspirin be continued at the minimum?
  • Would TTE be beneficial?
    • Reassuring exercise tolerance and absence of any symptoms.
    • Long term LAD ischaemia can lead to significant LV dysfx.
    • Low risk/stress surgical procedure

Plan

  • For discussion with surgical and cardiology teams to ensure that there has been no miscommunication about the timeline and to query if aspirin, at least, could be continued.
  • For TTE if time allows but wouldn’t delay surgery to obtain.
  • Update: Cardiologist contacted – unaware that the procedural cardiologist had stented the vessel (rather than just angiography) and so yes, surgery will need to be delayed for 1/12 of DAPT.