Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
54 years old / Gentleman
Known case of hypertension for the last 10 years.
Family history of IHD (older brother had CABG at 50 years of age).
Smoker (20 sticks /day)
Recent history of unstable angina in May 2015
Referred to us for coronary angiogram.
Symptoms of angina were on going.
Vital signs were stable.
CVS and respiratory examination did not reveal any abnormalities.
Relevant test results prior to catheterization
ECG: sinus rhythm
Trop T was negative
Renal profile: 5.2 / 139 / 5.0 mmol/L
Creatinine: 115 mmol/L
Full blood count: Hemoglobin 13.6 g/dL, WBC 8.3 x 109/l, Platelet 238 x 109/l
Echocardiogram: Ejection fraction was 67% (simpson' s method), valves were normal, no regional wall motion abnormalities
Relevant catheterization findings
1 st coronary angiogram was done on the 29th of May / 2015
LAD: Severe stenosis (90-99%) at bifurcation with diagonal (D1). Medina 1,1,1.
RCA: distal stenosis (80-90%) before bifurcation of PDA and PL branch
Initially PCI to RCA was done. The distal lesion was stented with biomime 3.5/13 mm and the bifurcation LAD/D1 lesion was planned for a stage PCI on 12 th of June 2015.
PCI to LAD
Right femoral approach. XB 3.5 7 F used as guide catheter. Run through floppy used as guide wire to wire down LAD. 2nd run through floppy wired down diagonal (D1). Pre dilated diagonal (D1) lesion with tazuna2.5/15 mm (Terumo) Pre dilated LAD lesion with Tazuna 2.5/15 mm.
Stented with ultimaster 2.75/38 mm (Terumo). Wires were flip flopped. IVUS was done to the LAD vessel. Noted there was a plaque proximally. LAD size was estimated at 3.5 mm proximally and at mid LAD it was 2.75 mm.
Unable to pass Hiryu 3.0/15 mm balloon (Terumo) for postdilatation. Catheter got disengaged.
Reengaged catheter and wired into LAD and D1 with run through floppy wires (wires were prolapsed during wiring). Still unable to pass Hiryu 3.0/15 mm balloon. Took out the D1 wire and tried again but still failed. Subsequently tried to pass NC euphora 2.75/12 mm (Medtronics), Tazuna 2.5/15 and 2.0/15 mm but still failed.
For better support, used a guidezilla and tried to pass a sapphire balloon1.0/10 mm (Orbus Neich) and still failed. Finally used a fine cross (micro catheter) and a whisper wire to wire down the LAD. Able to pass down tazuna 2.0/15 mm.
Predilated with 2.0/15, 2.5/15,3.0/15 and 3.5/15 mm. Stented proximal to the stent with a Cre 8 3.5/18 mm (CID) - overlapped). Proximal stent was postdilated with hiryu 3.0/15 and 3.5/15 mm. Kissing balloon technique to LAD/D1was done with hiryu 3.0/15 at LAD and Tazuna 2.0/15 mm at D1.TIMI 3 flow IVUS shows a well opposed and expanded stent.
The plan was to do a provisional stenting (single stent strategy). Side branch was wired and just in case flow was compromised, the strategy would be to do a reverse crush stenting.
However when we couldn't pass the post dilatation balloon, a few possibilities could be listed:-
a) wire went through the stent struts
b) intertwining of the wire
c) Opening of the stent was deformed by the calcium plaque during deployment (the reason in this case)
Hence, that is the reason why the vessels were rewired (with the wires prolapsed) and the diagonal wire was removed.
In order to have more support, guidezilla and double wire technique was used.
In short, the problem was settled with better guide support.