Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
The patient was an 88-year-old female who had treated for hypertension and diabetes mellitus. In March 2016, she felt chest pain when walking in a swimming pool during the rehabilitation after hip replacement.
Relevant test results prior to catheterization
In April, her home doctor detected poor R progression in ECG as well as pleural effusion in chest X-ray and introduced her to our hospital. Echocardiography revealed hypokinesis in the anterior and inferior wall with an ejection fraction of 40%.
Relevant catheterization findings
Coronary angiography showed left main (LM) aneurysm co-existing with severe calcified stenosis (90%) in its proximal site and the ostium of the left anterior descending artery (LAD) as well as 99% stenosis of obtuse marginal artery (images 1 and 2) and complete occlusion of right coronary artery (RCA, image 3). The patient preferred coronary intervention due to fear of high mortality and morbidity after bypass surgery (41% in STS score) regardless of high SYNTAX score of 46.
Firstly, the occluded RCA was treated with 3 drug-eluting stents (DES). In the 2nd session, an 8Fr guiding catheter (GC) was engaged to a left coronary artery via femoral artery under the support of intra-aortic balloon pumping. However, guidewire (GW) advancement with multi-functional probing catheter resulted in tangling in the aneurysm and failed its advancement even with the reversed wire technique (image 4). Although a thin-tip microcatheter (Caravel, Asahi Intec) barely slipped into a diagonal branch with a loop shape kept in the LM an aneurysm, a 1.0 mm balloon did not advance into the LAD. After LM calcified, lesion inflated with a 3.5 mm NSE balloon (Goodman), the GC could engage deeply and the GW facilitated to be advanced to the LAD (image 5). The severe calcified lesion in the LAD ablated with 1.75 and 2.15 mm Rota-burrs (Boston Scientific). The DES deployed in LM body and proximal LAD except for an aneurysm (image 6).
Left main aneurysm co-existing with calcified stenotic lesion led to be an annoyance for the GW advancement. In the treatment of such lesion, predilation with a scoring balloon in the LM body and consequent GC deep engage were effective for GW advancement and stabilization of the rotablation burr.