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Introduction: There are limited study data available of the effects of peripheral artery disease (PAD) on patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). According to the PROGRESS-CTO Registry results patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions and lower procedural success.1-3 We present the case of successful opening in stent CTO lesion of right coronary artery (RCA) in patient with PAD. Case report: 59-year-old man with a known history of a coronary vessel disease and PAD presented to our department due to frequent episodes of chest pain under minimal exercise and claudication and pain in the buttocks. The coronary angiography showed unchanged exam in left coronary basin. The RCA was completely occluded in segment two right in the area of the stent that was implanted eight years before. We found collaterals from the left coronary artery system and signs of calcification and autocollaterals for the distal segment of RCA, so the diagnostically criteria of a CTO were fulfilled. Because of the present symptoms of the patient and evidence for vital myocardium by echocardiography and myocardial scintigraphy revascularization of the CTO was performed. An AL 0.75 6F guidance catheter was used and the standard antegrade wire escalation technique attempted. A Turnpike Spiral catheter was inserted with the help of a ASAHI Fielder XT-A wire which was exchanged to an ASAHI Gaia Second which allowed the successful recanalization. Balloon angioplasty was performed with Abbot Traveler 1.5/15mm, Medtronic Euphora 2.57/15mm. Two sirolimus eluting stents (Terumo Ultimaster 3.0/38 mm and Ultimaster 3.0/30 mm) were successfully implanted with very good angiographic result. Three months later, chronic total occlusion of the left external iliac artery was treated successfully by percutaneous intervention and control coronary angiography showed unchanged exam in RCA. Conclusion: Our experience in this case demonstrates the feasibility of recanalization of an in-stent CTO in the patient with PAD and three months follow up showed improved of angina and quality of life. There is a definite and strong correlation between PAD and CAD. A concurrent PAD diagnosis is associated with higher rates of adverse outcomes following CTO PCI which requires additional monitoring.

Introduction and goal: The latest 2011 non-ST- segment elevation acute coronary syndromes (NSTE- ACS) management guidelines indicated that all patients should receive anticoagulation drugs irrespective of the treatment strategy. In this report, 2-year data on anticoagulation therapies for NSTE-ACS are presented, in relation to invasive management selection and treatment outcomes in a clinical setting without registered bivalirudin. Patients and Methods: Data for 374 patients with NSTEACS treated in the Coronary Care Unit in General Hospital Slavonski Brod, Croatia were analyzed from January 2012 to December 2013. Treatment strategies, outcomes and complications among patients treated with different anticoagulation agents (enoxaparine, fondaparinux or unfractionated heparin) were analyzed and compared. Results: In all, 72% of all NSTE-ACS patients were treated invasively, out of which 66% underwent angiography within 72 hours. Urgent and early angiography was performed in 44% of all invasively treated patients. Generally, 58% and 5% of patients received enoxaparine and unfractionated heparin (UFH), respectively, whereas fondaparinux was administered in 37% of patients. Median age of patients treated with enoxaparine was 66, compared to 76 in the fondaparinux group. There were significantly more patients treated with enoxaparine and UFH than with fondaparinux in the invasive strategy group. We observed that the number of patients treated with fondaparinux in the invasive group increased together with the period between symptom onset and angiography. The number of patients treated conservatively with either fondaparinux or enoxaparine was almost equal. There were no patients treated conservatively with UFH. In general, in-hospital mortality was low, 2.6% with no significant differences in bleeding events regarding the selection of anticoagulation therapy. Conclusions: Although the guidelines gave preference to fondaparinux, everyday practice in our hospital showed that enoxaparine was a preferred agent, particularly in younger patients selected for early invasive strategy, most probably because of the risk/benefit ratio and opportunity of avoiding the mixing of anticoagulation agents. Only 5% of patients were selected for urgent invasive approach with UFH, which should probably increase in the future. Considering a higher cost of bivalirudin, the introduction of this agent for non-ST segment elevation myocardial infarction management does not seem to be mandatory in our clinical setting, since this small group of patients was adequately managed with UFH.