Author + information
- Hui-Ping Zhang1
Patient initials or identifier number
Relevant clinical history and physical exam
The patient is male, 63 years old, presented with repeat rest angina. The patient has had chest tension after stress for 13 years, exacerbated 1 month. He has severe three vessels disease with LAD occluded, CABG undergone in 2012. Occluded SVG and poor LIMA flow demonstrated on angiography 4 months ago, sever stenosis at the middle of RCA was fixed with a stent inserted. Staged PCI aimed at LAD CTO planned. No lung rates and no abnormal heart sounds or murmurs heard.
Relevant test results prior to catheterization
LDL-C 1.46 mmol/l；eGFR 82 ml/min；ECG：Down sloping ST segment depression in I, avl and V2-V6 leads；UCG FindingsNo regional wall motion abnormality EF 60%，E/A<1.
Relevant catheterization findings
Coronary angiography performed in 2nd of September 2016. Unexpected severe stenosis in proximal RCA and diffused lesion at distal RCA revealed. The stent located at middle of RCA was good. Occluded LAD and severe stenosis in the ostial of LCX appeared no changes. His syntax score was above 50, Re-CABG refused, PCI was acceptable.
Step 1. Unexpected sever stenosis in proximal RCA and diffused lesion at distal RCA was fixed with stents implanted firstly.
Step 2. Retrograde approach via trans femoral access performed. Guide catheter of Medtronic 6F EBU 3.75 was placed to left coronary artery, Medtronic 7F AL 1.0 to RCA. Supported at the micro catheter of ASAHI Corsair, the wire of ASAHI Sion was retrogradely delivered to Diagonal-1 through the microchannel of septal. Supported at the microcatheter of Terumo Finecross, ASAHI Gaia Second failed antegradely penetrating the occlusion segment. Replaced with ASAHI Conquest pro, which succeeded penetrating the occluded point to reach Diagonal-1(two wires meeting).
Step 3. Dilated with balloon ostial to middle of LAD via the antegrade wire. Exchanged wire with a Terumo Run through floppy to Diagonal-1. We controlled the wire of ASAHI Conquest pro via the KANEKA Dual lumen micro catheter, which was hardly delivered to distal LAD. Balloon predilation.
Step 4. Faced with true left main bifurcation lesion, provisional T stents (two stents strategy) has to be adopted. Stents were implanted, postdilation with kissing balloon was performed.
The unexpected progressive lesion located at the non-targetvessel might hamper Staged PCI aimed at LAD CTO. Fixed the unplanned lesions firstly ensured the subsequent procedure to perform safely. Studying the angiographic findings carefully is absolutely. Well collateral provided the micro channel to penetrate occlusion segment bilateral directions. Two wires succeeding meeting from bilateral directions implied CTO lesion overcome. Sometimes, the KANEKA Dual lumen micro catheter is of importance. At last, the true left main bifurcation lesion was inevitable to deal with. We adopted the two-stents strategy of provisional T, the results seems acceptable.