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Relevant clinical history and physical exam
A 76 years old hypertensive non-diabetic patient admitted with rest anginal episode of 10 days duration. No previous history of any coronary intervention or MI. O/E– patient is hemodynamically stable with clinically clear lungs. Cardiac examination did not reveal any murmurs or s3.
Relevant test results prior to catheterization
ECG showed – NSR, diffuse T inversions in v1 to v6
2D echo showed RWMA in LAD territory, mild LV dysfunction
Relevant catheterization findings
The basal angiogram showed LMCA bifurcation lesion (1,1,1 )-tight stenosis of distal LMCA, ostial LAD and LCX with TIMI 3 flow distally. No other site significant coronary lesion. These were calcium in LMCA extending to LAD. An option of CABG discussed with the patient, which deferred by the patient.
In view of calcific LMCA disease, even precautions were taken for rotablation or cutting balloon.
LMCA engaged with 7F JL4 curve and both LAD and LCX were wired with choice extra support wires. Initially, LMCA to LAD was balloon dilated with 1.2 x 15 mm balloon, as there was difficulty in passing bigger balloon. Then cutting balloon of 3 x 15 mm used to brake the calcific lesion at the interpolated area of LMCA bifurcation. Then from proximal LMCA to LAD 3.5 x 20 mm xience prime stent deployed at 16 atms. There was mild resistance in a negotiation of stent. There was significant plaque shift to LCX causing severe pinching of LCX ostium. Then again LCX was wired with whisper and balloon dilated with 2 x 10 mm balloon. 3 x 15 mm another science prime stent was positioned in the LCX ostium taking the guide of the previous LMCA to LAD stent struts and deployed as 14 atm. After recrossing the LAD final kissing balloon dilatation done with 3 x 15 mm two balloons simultaneously with the final excellent result.
In this case, in the beginning, itself two-stent strategy planned as both LAD and LCX ostial are severe diseases as well as both the vessels are >2.5 mm size. Even though calcium was there as it was not very heavy calcium, we could do away with cutting balloon.