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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.

The acute coronary syndrome (ACS) network is a complex system of concern for patients with acute coronary syndrome. In order to provide adequate patient care, reduce total mortality and irrational costs of treatment, we need varied algorithms and a patient concern protocols. Outhospital emergency medical services, intrahospital emergency rooms, and coronary care units in percutaneous coronary intervention (PCI) and nonPCI centers participate in the care of ACS patients. Therefore, only algorithms adapted to each of these levels can improve the protocol for patient care. By standardized protocol implementation since January 2016, we compared the results with respect to the total number of patients before the protocol was applied. We analyzed the total number of patients, the relationship between the number of transferred and non-transferred patients, the intra-hospital mortality as well as the total mortality for ST- elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction patients (NSTEMI). The results show that the standardized protocol increases the total number of PCIs in patients with ACS, namely 36% for STEMI and 20% for NSTEMI. However, the total mortality of STEMI patients has increased from 5.2% to 6.9%, which is a consequence of an increased number of patients with cardiogenic shock (2.5% to 7.8%), as well as inappropriately high rates of transfer time from nonPCI hospitals (average time was 160 min). In patients with NSTEMI we recorded an increase in the total number of patients by 20%, while total mortality rate has not been changed. However, we should point out a favorable trend in the increase of PCI within 72 hours in NSTEMI patients. The standardized protocol, along with other organizational improvements, has led to the primary goal of increasing the number of primary PCIs in STEMI and PCI at ACS-NSTEMI at an early stage. It has also revealed the need for additional effort to increase the quality of treatment in terms of reducing patient delay time, proper recognition of STEMI by the outhospital emergency services, as well as the need to reduce transport time for transferred patients. If a transfer within 120 minutes cannot be provided we recommend pharmacoinvasive approach to be applied.