Author + information
- Huang Po-Yen1
Patient initials or identifier number
Relevant clinical history and physical exam
A 66-year-old man had a history of hypertension under regular medication control. He denied diabetes mellitus, smoking or relevant cardiovascular family history. He presented with acute onset chest tightness with diaphoresis about 6 hours ago. In our ED, his breath sounds were clear and regular heartbeats, blood pressure as 106/53 mmHg and heart rate as 57 b.p.m. ECG showed II, III, aVF ST elevation, so under the impression of STEMI, inferior wall, he was then sent to the cath lab for primary PCI for RCA.
Relevant test results prior to catheterization
The lab as follows: W.B.C. [10.6 x 103 /uL], Hb [15.8 g/dL], Platelet count [213 x 103 /uL], Glucose (Random) [168 mg/dL], Creatinine [1.00 mg/dL], S-GPT (ALT) [52 U/L], CK-Total [146 U/L], CK-MB mass [1.3 ng/mL], hs-Troponin I [7.9 pg/mL]. Cardiac echo showed Concentric LVH, mild AR, Adequate LV systolic performance, LVEF=77% and LV inferior-apical wall hypokinesis. Successful PCI with BMS for RCA.
Relevant catheterization findings
After PCI for RCA, coronary angiography also showed critical long stenosis from left main ostium to LAD-D with calcification and tortuosity, the relative small size of LCX. It is almost impossible to delivered guiding catheter into LCA due to bird-beak shape left main ostium.
Due to guiding catheter cannot engage well into LCA, it is extremely difficult to delivered wire, balloon and stents. First, we delivered extra-floppy wire into LCA with JL 3.5 7Fr guiding catheter then we use a variable technique to increase support strength, such as anchoring balloon, parallel wire, guidelinar catheter support and performed balloon dilatation from LM-ostium to LAD. During the procedure, the whole system jumped out twice and stent can't be sent to LCA, so we had no choice but change floating JL guiding catheter to 7Fr EBU guiding catheter under balloon anchoring. Finally, we deployed six drug-eluting stents from left main ostium to LAD-distal.
For critical LM-os lesion, how to increase support strength should be considered first such as a strong guiding catheter, anchoring balloon, Guideliner catheter and even parallel wire, these techniques were all essential to managing the tough lesion.