Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 57-year-old male presented with typical effort chest pain. He was ex-smoker and had a history of hypertension and hyperlipidemia. He also had a history of stable angina treated with percutaneous coronary intervention (PCI) in a proximal right coronary artery (RCA) five years ago and mid RCA 10 months ago.
Relevant test results prior to catheterization
EKG showed normal sinus rhythm without ST-T changes. Two-dimensional echocardiography showed normal left ventricular function without regional wall motion abnormality. Treadmill test was done and it showed significant down slope ST-depression with T wave inversion at stage 2. Maximum workload was 5.40 METS.
Relevant catheterization findings
Coronary angiography (CAG) revealed eccentric severe stenosis in mid left main (LM) to the ostium of a left anterior descending artery (LAD) which was very tortuous, angulated and calcified. Previous stent was patent without in-stent restenosis (ISR) in proximal and mid RCA. The lesion of LM to LAD was progressed, compared with the last CAG.
A 7Fr JL 4.0 SH guiding catheter engaged into LCA via right femoral artery. Under Crusade microcatheter support, Sion blue guidewire inserted to ramus and Sion black guidewire was inserted to LAD via the side port of Crusade microcatheter after several attempts. However, during retrieval of Crusade microcatheter, the wire in LAD accidentally removed together. Unfortunately, same maneuver could not lead successful rewiring. Along with Fin cross microcatheter support, LM to LAD wiring successfully done by reversed wire technique. After successful wiring, target lesion sequentially predilated with multiple balloon. Because the lesion was too tortuous and calcified, we tried to deliver a stent by balloon anchoring at LCX. However, the stent could not pass the lesion. We changed the stent to shorter one to pass the lesion. Nevertheless, it also could not pass. We left the guidewire in LAD and tried to change a guiding catheter to extra backup support. We approached via left femoral artery using a 7Fr EBU 3.5 guiding catheter. After successful parallel wiring to LM to distal LAD with Sion black under EBU guiding catheter. We removed the previous Judkins guiding catheter. To enhance access to the lesion and provide additional backup support, we tried ‘child-in-mother’ technique using the Guidezilla guide extension catheter. After successful wiring with Grand slam to achieve maximal wire support, serial predilation was repeatedly done. Finally, we deployed the stent successfully.
Because the anatomy of the lesion was very tortuous and calcified, it was more difficult to do wiring and deliver the stent to the lesion. To tackle severely angulated lesion for safe wiring, we used Crusade microcatheter and “Reverse wire technique”. And, to enhance access to the lesion and provide maximal back-up support, we tried parallel wiring, anchor balloon technique and finally “child-in-mother technique”. Because a long stent might be impossible to pass the very tough lesion, we decided to deploy two short stents instead of deploying a long stent.