Author + information
- Arvind Kumar Kandoria1
Patient initials or identifier number
Relevant clinical history and physical exam
60/F,k/c/o of HTN, CAD/AOE-II/III X 1 year with poor drug compliance and strongly positive TMT @ 7 METS.
Relevant catheterization findings
CART s/o TVD- prox. RCA 60%, mid RCA 70%, distal LCX after OM1 CTO with grade III collaterals from LAD and RCA, mid LAD 60%, distal LAD 70% stenosis with small caliber vessel and Right Dominant circulation
Plan was CABG vs. PCI. Patient opted for PCI.
• LMCA hooked with JL 3.5/6F coronary guiding catheter, lesion crossed with MIRACLE 3 wire and then replaced with BMW wire. Angioplasty done with 1.5 × 10 mm Sapphire II Balloon @ 12 atm × 15 seconds each twice.
• Haziness was present which was again dilated with 2× 10 mm Sprinter Legend Balloon @ 12atm × 15 seconds.
• Patient had developed flow limiting dissection. Biomime 2.5 × 29 mm stent deployed @ 16 atm × 25
seconds in distal LCX.
• Check angiography showed no flow.
• Patient was given i/c Nitroglycerine, Nicorandil, Adenosine and Tirofiban.
• Check angiography showed TIMI- II flow.
• i/v infusion of Tirofiban was continued for 18 hours. Check angiography next day revealed normal flow through and beyond stent. TIMI – III flow achieved.
• No flow/ Slow flow should always be kept in mind while tackling CTO other than PCI in ACS.
• Flow limiting dissection, coronary spasm and large thrombus should be ruled out before relabelling patient as true No flow/ Slow flow.
• If it persists, pharmacological agents should be used to tackle it.