Author + information
- Gurunath P. Parale1
Patient initials or identifier number
Relevant clinical history and physical exam
A 73 yr old lady presented with ACS.She had undergone Left main LAD cross over stenting as a salvage procedure for near cardiac arrest 2 yrs earlier. She had marked precordial ST segment depression and had low blood pressure. Diagnostic angiogram revealed patent stent but near cut off of ostial circumflex. Circumflex was arising at right angle to the left main and had acute proximal angulation.
Relevant test results prior to catheterization
EKG: Significant ST depression across precordial leads.
Echocardiogram: LVEF 30%. Regional wall motion abnormality in posterior, inferior lateral leads.
Troponin T positive.
Relevant catheterization findings
Diagnostic angiogram revealed patent stent but near cut off of ostial circumflex. Circumflex was arising at right angle to the left main and had acute proximal angulation. This posed challenge of hardware access across left main stent struts in the patient in agony.
EBU catheter was used to engage left main. Hydrophilc whisper guide wire was manipulated across the stent struts into the circumflex. Stent struts sequentially dilated starting with 1.2/6 balloon. Cx flow which had become sluggish after wiring was reestablished. However getting stent across was difficult because of the right angle Cx take off and its acute proximal angulation. Patient repeatedly was developing angina, hypotension with every unsuccessful attempt of stent passage with careful manipulation of catheter, wire biomime stent was deployed. End result was pleasing with prompt relief of symptoms and improvement of hemodynamics.
Every now and then interventionalist come across difficult clinical situations. This needs to be addressed with due planning, appropriate use of hardware and daring decision making. This aided by lady luck can help salvage difficult situations as exemplified by this case that was clinically unstable having complex coronary anatomy.