Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
An 82-years-old male suffered chest pain and dyspnea for 6 hours. He has the history of hypertension. Initial his EKG showed ST-segment elevation in II, III, aVF lead and ST-segment depression in other lead, except AVR lead. His blood pressure was 85/47 mmHg and heart rate was 114 bpm.
Relevant test results prior to catheterization
Initial his electrocardiogram showed ST-segment elevation at II, III, aVF lead and ST-segment depression in other lead, except aVR lead. In his Chest X-ray showed cardiomegaly and pulmonary edema.
Relevant catheterization findings
In coronary angiography, there was heavily calcified and significant stenosis of distal LM to proximal LAD, and there was discrete stenosis of proximal LCx with extreme tortuosity, but LCx ostial was preserved. RCA was chronic total occluded. After coronary angiography, patients' blood pressure dropped to 65/45 mmHg. We escalated the vasopressors and we decided to apply the ECMO before PCI.
First, we performed the PCI, targeting proximal LCx. We used the 7Fr Judkin left 4 guiding catheters and performed the balloon using 2.0 mm and then stepwise up to 2.5 mm balloon. And we advanced the stent through the distal LM to proximal LCx angled lesion, however. A stent was not passed. We performed the balloon at culprit lesion, several times, but stent was not passed. So, we used Guidezilla TM guide extension catheter, but we failed to advance the stent through the lesion. We changed the guiding catheter from JL to XB 3.5. However, despite the change the guiding catheter and using Guidezilla TM, we failed to advance the stent again. Finally, we performed the buddy wire technique and stent succeeds to pass through the lesion. We performed the PCI with stenting at distal LM to proximal LAD lesion. We could wean the ECMO after 2 days and patient discharged after 7 days.
Prophylactic ECMO support PCI was reasonable and useful treatment option for a high-risk very unstable patient. Guiding catheter and wire support are the most important factor of procedure success. Especially, Buddy-wire technique provides the guiding catheter stability and straightens the tortuous segment of the artery. Also, this technique deflects the stent delivery system away from the calcified area.