Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation

Abstract

Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end-stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare-metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 Â 10 9 /L, the median international normalized ratio was 1.3, and the median Model for End-Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in-hospital or 30-day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1-U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation. End-stage liver disease (ESLD) is associated with increased cardiovascular risk. 1 Although the prevalence of coronary artery disease (CAD) was previously thought to be lower in patients with ESLD versus the general population, multiple studies have demonstrated an increased prevalence of CAD in this subset of patients. [2][3][4][5][6] The overall prevalence of CAD in patients with ESLD has been reported to be 20% to 28%, with the highest prevalence being reported in patients over the age of 50 years. 2,6,7 The ideal management strategy for liver transplant candidates with CAD remains unknown. The 3-year mortality rate of patients with CAD undergoing orthotopic liver transplantation (OLT) has been reported to be 26% to 50% whether medical management or surgical revascularization is pursued. 8,9 Coronary artery bypass grafting before OLT can accelerate or exacerbate liver failure 10 and has been associated with increased morbidity and mortality. 11 Percutaneous coronary intervention (PCI) with stenting has Abbreviations: CAD, coronary artery disease; ESLD, end-stage liver disease; INR, international normalized ratio; MELD, Model for End-Stage Liver Disease; OLT, orthotopic liver transplantation; PCI, percutaneous coronary intervention; PTCA, percutaneou...

Role of cardiac catheterization and percutaneous coronary intervention in the preoperative assessment and management of patients before orthotopic liver transplantation

“…[12][13][14][15] As for kidney injuries, according to the RIFLE criteria, 6 of the 469 individuals developed a risk of renal dysfunction, and 7 developed a kidney injury. Liver-kidney transplantation was more frequently performed in period B (8%) versus period A (2.9%, P < 0.001), but the rate decreased in period C (3.4%) versus period B (P 5 0.04), even though the PCI rates increased with each period…”

The Morbidity and Mortality Risks following Percutaneous Coronary Interventions in Cirrhosis

“…This manifestation of cirrhosis is due to blood stasis in the portal veins, which induces markedly higher pressure within the portal veins, and subsequently results in extrahepatic portosystemic shunts and varices [21]. Also, secondary to the decline of hepatic synthetic function, alterations in vasoreactive substances contribute significantly to the pathophysiology of portal hypertension characterized by increased intrahepatic vascular resistance and hyperdynamic circulation [22].…”

NAFLD and liver transplantation: Current burden and expected challenges

“…A clear strategy for revascularization can be challenging and controversial, however. Stent placement will require one and occasionally two anti-platelet agents, potentially delaying transplant and revascularization by coronary artery bypass grafting is associated with high morbidity and mortality in patients with decompensated cirrhosis [141,142]. …”