Author + information
- Dede Moeswir1
Patient initials or identifier number
Relevant clinical history and physical exam
A 63 year-old man referred for complex angioplasty. He had suffered for effort angina about 7 months. He always feels fatigue if doing some mild activities and many spent time with take a rest. His coronary risk factors were hypertension, diabetes mellitus, dyslipidemia and he takes drugs bisoprolol 5 mg, clopidogrel 75 mg, as cardiac 80 mg, atorvastatin 20 mg OD and cedo card 5 mg sublingual when patient feel chest pain. The physical examination was normal.
Relevant test results prior to catheterization
The ECG revealed old anterior infarction and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (LVEF=61%), The patient cannot take treadmill test because of fatigue when doing some exercise.
Relevant catheterization findings
The coronary angiogram showed 80% stenosis lesion at mid-distal left main and pLAD, mild stenosis at pLCX and 90% stenosis at mRCA.
The left radial artery inserted through 7Fr sheath. The left coronary artery engaged with a 7Fr BL3.5 guiding catheter. A 0.014 inchSion, BMW, and Run through were used to wiring LAD, LCX and Diagonal 1. Predilatation performed with NC Saphire 2.5 x 15 mm balloon and NC trec 3.5 x 15 mm balloon at mid-proximal LAD and Diagonal 1 branch several times. As slow flow of LAD was observed after predilatation, patient feel more chest pain with unstable hemodynamic, we decided to implant stents at mid LAD, Xience Prime 2.5 x 28 mm and resolute integrity 3.0 x 22 mm stents were successfully deployed at mid to proximal LAD. After stent implantation, we do rewiring Diagonal 1, post dilatation mid-proximal LAD performed with NC trec 3.5 x 15 mm balloon. After rewiring LAD-LCX, we did crush technique for stent at LAD with NC Trec 3.5 x 15 mm balloon and we decided to implant stents at LM-LCX with Combo. 4.0 x 18 mm stents were successfully deployed, after rewiring again we do open the strut at LM-LAD was performed with NC sapphire 1.5 x 15 mm, 2.0 x 15 mm and 2.5 x 15 mm balloon. At last, the final kissing balloon performed with NC Saphire 3.0 x 20 mm balloon at LM-LAD and NC Trec 3.5 x 15 mm balloon at LM-LCX. Final angiography showed well-expanded LM-LAD-LCX.
We perform high risk PCI bifurcation calcified LM-LAD-LCX lesion with DK-Crush technique even with severe chest pain and hemodynamic instability successfully with a good result, we suggested use left radial artery access because more easily to maneuver and do final kissing balloon technique to get a better outcome.