Author + information
- Satoshi Yamamoto1
Patient initials or identifier number
Relevant clinical history and physical exam
A 40-year-old male. He had no past medical history. He called for an ambulance because of chest pain. He was clear and alert at the time of contact by ambulance team. On the way to our hospital, he felt into cardiopulmonary arrest and underwent cardiopulmonary resuscitation including electrical defibrillation in the ambulance. At the arrival at our hospital, a return of spontaneous circulation was confirmed.
He was pale with cold sweating. He showed cardiogenic shock with systolic blood pressure 80 mmHg.
Relevant test results prior to catheterization
His 12 leads electrocardiogram (ECG) showed sinus tachycardia at the rate of 127 bpm. We could see complete right bundle branch block and ST elevation in I aVL V1-4 and also in aVR, and depression in II III aVF. The echocardiogram demonstrates diffuse left ventricular asynergy. The chest roentgenogram showed pulmonary congestion.
Relevant catheterization findings
Immediately after he was moved to catheterization laboratory, his ECG turned pulseless electrical activity. We initiated percutaneous cardiopulmonary support (PCPS) and intra-aortic balloon pumping (IABP). Coronary angiogram showed totally occluded left main trunk (LMT).
Guiding Catheter: 7Fr. Launcher SL4.0.
Guide wire: Asahi Route (LAD), Run through extra-floppy (LCX)
Soon after wire crossing the lesion, TIMI II flow was restored. The angiogram showed filling a defect in LMT and small aneurysm at just proximal of LAD. We dilated the lesion with 3.0 x 12 mm balloon (LAXA). We took Intravascular Ultrasound (IVUS) image pulling back from both LAD and LCX. IVUS image detected ruptured plaque in LMT and aneurysm at ostium LAD which might have continuity with the ruptured plaque.
We deployed a drug-eluting stent (DES) (Nobori 3.5 x 24 mm from LMT to LCX. To make kissing balloon technique (KBT), we tried to recross another wire (Sion Blue) to LAD through stent strut using a multifunctional catheter (Crusade K). Although we felt some difficulty to recross because of an aneurysm, we could clear with step by step strategy. We put another DES (Nobori 3.5 x 24 mm) from LMT to LAD with culotte manner. We successfully treat the lesion.
We successfully treat the lesion with culotte stenting. Culotte stenting needs twice of recross of wire through stent strut. The gold standard of recrossing is “The more distal, the better”. Although, it is recommended more when LMT culotte stenting, it is sometimes difficult. In this case, LAD rewiring was difficult because of an aneurysm around at recrossing point. We could clear with small technical tips using a multifunctional catheter.