What is the best management approach for an elderly patient with a history of coronary artery disease (CAD), previous stenting with a Cypress stent (likely a drug-eluting stent) to the left external iliac artery (LEIA) and a ST-elevation myocardial infarction (STEMI) treated with drug-eluting stents (DES) to the obtuse marginal 1 (OM1), also having a history of multiple hip replacements, nerve injury, transient ischemic attack (TIA), chronic kidney disease (CKD) stage 3, and recent computed tomography angiography (CTA) showing mesenteric stenosis of the celiac artery and high-grade stenosis of the popliteal artery in the left lower extremity?

Management of Complex Multi-System Vascular Disease in an Elderly Patient

Direct Recommendation

This elderly patient with extensive coronary, peripheral, and mesenteric vascular disease requires immediate dual antiplatelet therapy (aspirin 75-100 mg plus clopidogrel 75 mg daily), high-intensity statin therapy, ACE inhibitor, and urgent multidisciplinary Heart Team evaluation to determine optimal revascularization strategy given the complexity of disease across multiple vascular beds. 1, 2

Immediate Medical Management

Antiplatelet Therapy

• Continue aspirin 75-100 mg daily indefinitely as the patient has established CAD with prior stenting 2, 1
• Add or continue clopidogrel 75 mg daily given the patient has drug-eluting stents placed for prior STEMI and ongoing high-risk peripheral arterial disease 2, 3
• The combination of aspirin plus clopidogrel is indicated for 12 months post-stenting, but in this patient with severe multi-level peripheral arterial disease, extended dual antiplatelet therapy beyond 12 months is reasonable 2
• Avoid prasugrel or ticagrelor in this elderly patient given the history of TIA (prasugrel is contraindicated with prior stroke/TIA) and increased bleeding risk with advanced age and CKD stage 3 2, 1

Lipid Management

• Initiate or continue high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) immediately, targeting LDL-C <70 mg/dL (1.8 mmol/L) 1, 4, 5
• Statins provide plaque stabilization, anti-inflammatory effects, and improved endothelial function critical for multi-vessel atherosclerotic disease 5

Renin-Angiotensin System Blockade

• Start ACE inhibitor (or ARB if ACE inhibitor not tolerated) given the patient's CAD, prior MI, and CKD stage 3 1, 4, 5
• ACE inhibitors reduce cardiovascular morbidity and mortality in peripheral arterial disease patients regardless of hypertension status 5
• Dose adjustment required for CKD stage 3: calculate creatinine clearance and adjust all renally-cleared medications accordingly 2, 1

Beta-Blocker Therapy

• Continue beta-blocker therapy given the history of STEMI, as long-term beta-blocker use post-MI improves survival 2
• Ensure the patient is hemodynamically stable without heart failure exacerbation, bradycardia, or heart block before continuing 2

Risk Stratification and Revascularization Strategy

Heart Team Evaluation

• Urgent multidisciplinary Heart Team consultation is mandatory given the complexity of three-vessel coronary disease (prior stents to left external iliac artery and OM1), high-grade popliteal stenosis, and celiac artery stenosis 6
• The Heart Team should include interventional cardiology, cardiac surgery, vascular surgery, and nephrology given CKD stage 3 6

Coronary Assessment

• Determine current coronary anatomy and stent patency through coronary angiography if clinically indicated by symptoms or non-invasive testing showing ischemia 2
• Given the patient's extensive comorbidities (multiple hip replacements, nerve injury, TIA history), CABG may be preferred over PCI if significant multi-vessel disease is present, particularly if diabetes is also present 2
• CABG is reasonable in elderly patients with complex three-vessel CAD to reduce cardiovascular events and improve survival 2

Peripheral Arterial Disease Management

• The high-grade left popliteal artery stenosis requires urgent vascular surgery evaluation for potential revascularization given the risk of critical limb ischemia 5
• Consider cilostazol 100 mg twice daily for symptomatic claudication if present, though contraindicated if heart failure exists 5
• Avoid any further catheter-based procedures through femoral access if possible, given the risk of cholesterol embolization syndrome with manipulation of atherosclerotic vessels 7

Mesenteric Stenosis Evaluation

• The celiac artery stenosis suggestive of median arcuate ligament syndrome requires further evaluation with duplex ultrasound during expiration and inspiration to confirm hemodynamic significance 2
• If symptomatic (postprandial abdominal pain, weight loss), consider surgical release of median arcuate ligament or endovascular intervention 2
• If asymptomatic, conservative management with medical therapy is appropriate 2

Special Considerations for Elderly Patient with CKD Stage 3

Medication Dosing Adjustments

• Calculate creatinine clearance (CrCl) using Cockcroft-Gault equation and adjust all antiplatelet and anticoagulant doses accordingly 2, 1
• Use weight-based dosing where appropriate to reduce bleeding risk in this elderly patient 2
• Avoid or minimize iodinated contrast during any future angiographic procedures to prevent contrast-induced nephropathy in CKD stage 3 2, 1
• Ensure adequate hydration before and after any contrast exposure 2

Bleeding Risk Mitigation

• Add proton pump inhibitor (PPI) given dual antiplatelet therapy and multiple risk factors for gastrointestinal bleeding (age ≥65 years, likely on chronic medications) 2, 1, 4
• Evaluate baseline hemoglobin and monitor for anemia given the increased bleeding risk with dual antiplatelet therapy in elderly patients with CKD 2
• Avoid routine blood transfusion unless hemoglobin <8 g/dL in hemodynamically stable patients 2

Patient-Centered Decision Making

• Management decisions must consider the patient's functional status, cognitive status, life expectancy, and goals of care given advanced age and multiple comorbidities 2
• Assess frailty before proceeding with any invasive revascularization procedures 2

Critical Pitfalls to Avoid

• Do not perform urgent PCI or angiography through femoral access without careful consideration of cholesterol embolization risk given extensive atherosclerotic disease 7
• Do not use prasugrel given the history of TIA (Class III: Harm recommendation) 2, 1
• Do not discontinue antiplatelet therapy prematurely as this increases risk of stent thrombosis and cardiovascular events 2
• Do not use fondaparinux as sole anticoagulant if PCI is planned (Class III: Harm) 2
• Do not administer NSAIDs (except aspirin) given increased risks of mortality, reinfarction, and bleeding 4
• Do not proceed with complex revascularization without Heart Team discussion given the complexity of multi-vessel, multi-system disease 6

Ongoing Monitoring and Follow-Up

• Cardiac rehabilitation program enrollment is recommended to improve functional capacity and secondary prevention 4
• Annual influenza vaccination is indicated for all patients with cardiovascular disease 2
• Regular monitoring of renal function given CKD stage 3 and use of multiple renally-cleared medications 2, 1
• Assess for symptoms of mesenteric ischemia (postprandial pain, weight loss) and peripheral arterial disease progression (rest pain, tissue loss) 2, 5