Author + information
- Debasis Mitra1
Patient initials or identifier number
66 year old gentleman
Relevant clinical history and physical exam
66 years old hypertensive non-diabetic obese gentleman presented with recurrent chest pain and reduced exercise tolerance for 2 months. Symptoms increased for last 15 days.
On presentation blood pressure was: 140 / 90 mmHg
Pulse: 76 beats / minute
Relevant test results prior to catheterization
ECG Showed complete LBBB, Sinus Bradycardia
ECHO: No RWMA, Good LV systolic function with LVEF: 65%. Grade I diastolic dysfunction
Hb: 13.7 mg / dl
Creatinine: 1.4 mg /dl
FBS: 95 mg / dl
Total Cholesterol: 271 mg / dl. LDL: 154 mg / dl. Triglyceride: 203 mg / dl
Chest X ray: Normal.
Relevant catheterization findings
LAD: Good vessel caliber. Showed 99% discrete lesion at the LAD - D1 Junction. Good distal flow
D1: Good vessel caliber. Showed 99% stenosis at the ostium. Good distal flow
RCA: Minor plaque (distal RCA)
Rena: Right Renal artery stenosis
A 7F XB 3.0 guide catheter was placed through femoral approach. One 0.014” X 180cm stabilizer super soft wire was parked into the LAD and another 0.014” X 180 cm stabilizer super soft wire was placed into D1. Pre-dilatation of LAD was done with 2.5 X 12 mm Trek balloon and D1 was predilated with 2 x 15 mm mini trek balloon. D1 stenting was done with 2.5 X 16mm Promus element at 12 atm. First crush was done with 2.75 x 15 mm balloon and first kiss was done with 2.75 x 15 trek in LAD and 2.5 x 15 mini trek in D1. Stenting of LAD was done 3 x 20 mm promus element (Second Crush) and post dilatation was done with 3.5 X 8 NC trek balloon. Trans strut wiring was through LAD stent into the D1 stent and trans strut dilataion was done with 1.5 x10 mm balloon. Second kiss was done by keeping NC trek 3.5 X 8 mmballoon in LAD and by keeping NC trek 2.75 X8 mm balloon at D1. POT to LAD was done with 3.5 x 8 mm NC trek. Finally ostiumLAD was stented with 4 X 12 mm promus element and post dilated with 4.5 X 8 NC trek at high pressure.
Finally motorized pull back was done with Atlantis proIVUS catheter 3.6 F. Preand post IVUS study was done. After stenting the IVUS study was done to ensureproper deployment of stent. The stent struts were shown to be properly apposed with no evidence of edge dissection.
The available clinical data support the advantages of DK crush over other stenting techniques for more complex coronary bifurcation lesions.
Imagingmodalities are useful to guide SB rewiring and assessment of procedure quality.
Complex bifurcation PCI under IVUS guidance ensures good long term clinical results. Patient is followed up at 3 months and 6 months and 9 months & doing well.