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Patient initials or identifier number
Relevant clinical history and physical exam
A 57-year-old male presented with exertional angina for three weeks. His coronary risk factors include hypertension, dyslipidemia, and smoking. The heart rate and blood pressure were 91 /min and 130/70 mmHg, respectively. Other examinations were unremarkable.
Relevant test results prior to catheterization
Baseline ECG and CXR were normal. Exercise stress test was positive for ischemia at lateral leads. The computed tomography (CT) coronary artery total calcium (Agatston) score was high (1346).
Relevant catheterization findings
1. Left main trunk (LMT) was normal.
2. Left coronary angiogram showed mild disease at proximal left anterior descending (LAD) artery and a mid-LAD 50% lesion
3. Ostial diagonal artery was critically diseased (99%) with abrupt angle branching from LAD
4. Left circumflex (LCX) artery was normal
5. Right coronary artery (RCA) was normal (dominant)
He was treated medically initially but experienced recurrent angina despite optimal medical treatment. He was scheduled for PCI.
The LMT was engaged with a 6 Fr XB 3.0 guiding catheter (GC) via right radial artery using a 6Fr radial sheath. First, a BMW was used.However, we failed to cross the critical ostial diagonal branch by using the conventional wiring technique because of unfavorable coronary anatomy. A series of different wires (BMW, Run through, CHPT and Sion Blue) with different curves and angle were used but encountered difficulty in crossing the narrowest entry point of the occluded branch. Subsequently, we adopted a wiring technique assisted by a double-lumen microcatheter (CRUSADE, Kaneka) positioning in LAD. By careful manipulation of a new BMW guidewire through the side hole of the double-lumen microcatheter, we successfully crossed the BMW wire into diagonal artery. Of note, other technique such as reverse bent wiring technique was considered but not required in this case. Following successful wiring, withdrawal of the CRUSADE catheter was attempted by balloon trapping technique, but failed because of 6Fr GC (instead of 7Fr) was used in the first place. Fortunately, the CRUSADE catheter was withdrawn by wire extension technique. The lesion was treated by angioplasty (Sequent Neo 2.0x 10 mm), and a stent (Coroflex ISAR 2.5 x 14 mm) was implanted in the diagonal artery covering the ostium with good angiographic result. The mid-LAD lesion was treated conservatively. Patient’s angina relieved after PCI. Later, in the follow-up outpatient clinic, the repeat exercise stress test was normal.
Double-lumen microcatheter is useful in facilitating the wiring of the critically narrowed ostial side branch and increase the rate of success when the conventional wiring techniques failed. The device is safe and convenient to use especially when the rapid exchange of different types of wires is required. However, in our case, a 7 Fr guiding catheter is recommended for easier retrieval of the double-lumen microcatheter.