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Relevant clinical history and physical exam
Age: 35, Sex: male
Chief Complaint: effort chest pain for 1 year, more severe 2 months.
Present Illness: 1 years ago, after working the patient always felt chest pain, more severe in the left side, radiating to neck and both arms, gradual onset over 5-10 minutes.Then the patient went to the hospital in his town, the24 hours ECG examination shown myocardial ischemia, given some drugs for pain-control. After having some drugs (GTN, glyceryl trinitrate) and more rest, the symptoms lightened. But 2 months ago, without significant causes, the symptoms became more severe.
Past history: the patient had a history of hypertensionfor about 3 years.
No history of smoking and alcohol use.
No history of chronic diseases like CAD and mellitus diabetics. No history of dizziness andheadache. No history of hepatitis or AIDS, tuberculosis.No history of trauma and operation. No history of hypersensitivity of any drug or food.Denying the family history of any heredity diseases or diabetes mellitus(DM), CAD, No history of exposure to poison.
Systems review: Respiratory system, circulation system, digestive system, urogenital system, hemopoeltic system, endocrine and metabolic systems, musculoskeletal system, metabolic and endocrine system, nervous system and motor system no abnormal.
Physical examination: Temperature: 36.5oC; pulse rate: 72/min; respiratory rate: 18/min; blood pressure: 130/80mmHg.
General condition: normal development, eutrophic, normal body shape, conscious, spirit is poor, medium nutrition, irritability, hands, limbs, tamper with co-operative examination, facial flushing. Automatic postures, screening cooperation. Skin and Mucous Membrane, Lymph glands; Head and Skull, Ear, Nose, Mouth, Neck, Chest; Lungs, heart, abdomen (inspection, palpation, percussion, auscultation),external genital organs, spine and limbs, nervous system. Specialized examination: conscious, spiritual difference, no lips cyanosis, tracheal center, barrel chest, both sides of the tactile language to reduced sound chatter, percussion was too voiceless, lungs breath sounds low, smells, and low scattered in the dry rales sound.
Relevant test results prior to catheterization
WBC count (normal), Hemoglobin (normal), Platelet count (normal), CK-MB(-), Myoglobin (-), High-sensitivity troponin I (-), BNP (-), Total protein (normal), Albumin, TG (6.5 mmol/L), TC (normal), HDL (normal), LDL (2.1mmol/L), Baseline electrocardiogram (ECG)showed no significance ST-segment elevation or depression (Figure.1). Echocardiography show EF 50% and without regional wall motion abnormality.
Relevant catheterization findings
Coronary angiography (CAG) highlighted a sub-occlusive stenosis of the proximal left anterior descending artery (LAD)(the main branch-MB) involving the first diagonal branch (the side branch-SB) (Figure.2A and B, arrow). Mid right coronary artery (RCA) 30% stenosis (Figure. 3A and B).
1. Coronary angiography (CAG).
Both therapies (before the CAG procedure) include treatment with: Dual platelet inhibition (DAPT),aspirin (100 mg/qd) plus second anti-platelet agent (ticagrelor 90 mg/bid);Anti-coagulant (heparin, administered in catheter lab for primary percutaneous coronary intervention, PPCI); Oral beta blockers (metoprolol23.75 mg/qd); ARB (valsartan 80mg/qd); statins (atorvastatin mg/qn).
(1) The coronary angiography (CAG)was performed via the trans-radial approach: 6F sheath was inserts into right radial artery and CAG was performed by the 5F left and right coronary angiography catheter.
(2) The result of left coronary artery (LCA) CAG show: left coronary artery CAG highlighted a sub-occlusive stenosis of the proximal left anterior descending artery (LAD) (the main branch-MB) involving the first diagonal branch (the side branch-SB) with the slow flow phenomenon (Figure. 2A and B, arrow); left main artery no significant stenosis; the left circumflex (LCX) no significant stenosis.
(3) The result of right coronary artery (RCA) CAG show: Mid RCA 30% stenosis (Figure. 3A and B).
After CAG we communicate with patient and family. The patient and family refused to stent implantation and coronary artery bypass grafting (CABG); so we opted for a total-drug coated balloon (DCB) angioplasty without stent implantation.
2. The first time percutaneous coronary interventions (PCI).
(1) Changing the diagnostic catheter to a 6F EBU 3.5 guiding catheter.
(2) The LCA ostium was engaged with 3.5 EBU guide catheter.
(3) Run through guid wire was inserted through the guiding catheter and positioned in distal LAD.
(4) Since the patient was refused to stent implantation and CABG, we opted for a total-drug coated balloon (DCB) angioplasty.
(5) A 3.0 × 15 mm cutting balloon was positioned at the target lesion and pre-dilation of the lesion was performed with the cutting balloon (10-12 atm).
(6) The CAG after cutting balloon pre-dilation show the residual dissection, but the distal LAD flow is better.
(7) In order to achieve optimal apposition, we plan to prefer the quantitative angiography with optical coherence tomography (OCT) or intravascular ultrasounds (IVUS), but the patient and family refused to do IVUS and OCT. Therefore, there is no IVUS and OCT image.
(8) Subsequently, a 3.0 × 26 mm DCB was positioned at the target lesion and the DCB dilatation was performed (at nominal pressure) from proximal LAD to mid LAD.
(9) Glycoprotein IIb/IIIa inhibitors (tirofiban) are given in procedures.
(10) The final angiography showed a mildly improved angiographic result with dissection.
(11) During the procedure, the hemodynamics stable and the electrocardiography (ECG) no significant depression and elevation, in addition, the patients no significant chest pain.
(12) Given the clinical history of the patient and the unimpaired distal flow we decided not to stent the lesion (Figure. 4A and B, arrow).
(13) The patients no significant chest discomfortable and the ECG no significant changes.
(14) The patient was discharged with dual antiplatelet therapy (aspirin 100mg/qd and clopidogrel 90mg/bid), ARB (valsartan 80 mg/qd) and statins(atorvastatin mg/qn) four days later.
3. Five month scheduled CAG.
(1) The follow up CAG was performed via the trans-radial approach: 6F sheath was inserts into right radial artery and CAG was performed by the 5F multifunctional coronary angiography catheter.
(2) The result of left coronary artery (LCA) CAG show: Proximal LAD with a lumen enlargement without dissection (Figure. 5A and B, arrow); left main artery no significant stenosis; the left circumflex (LCX) no significant stenosis.
(3) The result of right coronary artery (RCA)CAG show: Mid RCA 30% stenosis.
4. Twelve month follow-up without CAG or coronary computed tomography angiogram (CTA)examination.
Drug-coated balloon (DCB) has emerged as an novel device for percutaneous coronary intervention (PCI), which has demonstrated favorable outcome due to its peculiar characteristic of a high-concentration, rapid local arterial tissue delivery of ant proliferative drugs (paclitaxel, sirolimus, or everolimus) by single prolonged coated balloon angioplasty inflation, and prevents restenosis, leaving no implant polymer or metal stent. DCB have so far been the most promising non-stent based approach for local drug delivery in both preclinical and clinical trials. The last decade witnessed the emergence of DEB as an attractive alternative therapeutic strategy of coronary revascularization for selected patients. Nowadays, the use of DEB has been mainly advocated in patients with in-stent restenosis (ISR). Moreover, DCB is regarded as the optimal treatment for coronary lesion subsets, such as small vessel disease or side branch bifurcations, in which the implantation of a drug-eluting stent is not desirable. Thanks to these pharmacokinetic properties, recently DCBs have also shown to be able to improve vessel healing after a dissection is left at the end of PCI. However, DES exhibits some device-associated features and shortcomings only solved in part by newer brands and new generations. In addition, some studies have shown DCB to improve vessel diameter at long term follow-up, with a phenomenon called “late vessel enlargement”. The positive vessel remodeling may be the main cause of the phenomenon, as well as the possibility of plaque regression and vascular healing being partly responsible for the late lumen enlargement. The case described here shows both these properties of DCB to cause late vessel enlargement and healing after a residual dissection. Other studied using more precise imaging technology to verify and better understand the phenomenon is expected in the future.