Knowing when to stop

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Knowing when to stop

There’s a delicate balance in medicine when performing a procedure on the human body. Each patient is different; human biology is not stereotyped despite vast homogeneity of physiological principles. In attempting to reach a therapeutic objective one has to gauge how hard to try, when to push, when to let up, when to quit.

Coronary intervention is no different. Here’s a general guide to the technique. Study this description for a while and then come back.

OK, you studied, now you’re ready? Recently I had a patient with recurrent angina despite the best in medication therapy. We decided to perform a diagnostic coronary angiogram to examine his native coronary arteries as well as his bypass grafts ( he had undergone previous bypass surgery many years previous). Turns out there was a severe blockage in the native coronary artery supplying the bottom part of his heart. At the outset, it looked straightforward: about a 90-95% narrowing but in an accessible region of the artery with a reasonable diameter to the vessel. So I began. The first clue was that it was difficult to find a guiding catheter that stayed put. Although the guide wire went down easily, every time I tried to advance a balloon, the guide catheter disengaged from the artery back out into the aorta. I then tried multiple different combinations of guide catheter, wire, double wires, shorter balloons, smaller balloons mixed with small aliquots of cursing, praying, and hoping. It looked doable, and I didn’t want to give up. Fortunately the patient was stable and not symptomatic during the procedure. At one point, I actually managed to make the artery worse with the initial severely limited flow now being no flow at all-that is not a good thing. The staff in the room were getting restless, and I was wondering where the risk/benefit ratio now was. Every new combination of hardware meant more time, more fluoroscopy, more radiation, more contrast potentially toxic to the kidneys, and more frustration. Every re-engagement of the guide catheter increased the risk of dissection. Every new wire brought the hazard of perforation. But the patient had not been helped yet.

Finally, with a certain combination of catheter, two wires, smaller balloon, and perseverance, I managed to get the balloon across the lesion and inflated. Stenting followed with a good result. The patient was quiet and without complaints. Everyone in the room was relieved to be done.

Similar scenarios occur in any medical procedure. Sometimes you can’t get it done. Sometimes the result isn’t perfect. Sometimes you violate the principle of “primum non nocere” because taking no risk means getting no useful improvement. “The enemy of good is ‘better’”, a wag once uttered. But the enemy of bad is sometimes gritty effort with measured calculation-where’s the philosopher for that one?\
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