Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 78-year old woman regularly came to our patient clinical because of diabetes mellitus (DM) requiring insulin use and hypertension. One day she came to the clinic, complaining of her exertional dyspnea during the last week. Her prior medical history also included ischemic heart disease (CABG and PCI in proximal RCA and proximal LCX). After meticulous examination, she had congestive heart failure.
Relevant test results prior to catheterization
The echocardiography showed anterior wall asynergy, which was not seen before. The ejection fraction decreased from 51% to 36%.
Relevant catheterization findings
The CAG showed patent Aorta-SVG-RCA graft, LITA-HL graft and RITA-LAD graft. It also demonstrated totally occluded ostial LAD protected by RITA and moderately stenotic proximal LCX (the proximal edge of the implanted stent). The What was more important was the kinking of RITA graft with moderate tortuosity without delayed flow.
After the engagement of guiding catheter, we placed a dummy wire in LCX and started wiring to CTO. We exchangedXTR to gaia 2nd. The Gaia 2nd could be advancedto diagonal branch. Finally we could advance a wire into distal LAD. Then, we placed a micro catheter indistal LAD. After equalization of pressure wire in the aorta,it was advancedinto the micro catheter. Afterconfirming the occlusion of LAD by the micro catheter, we measured FFR atbaseline and at hyperemia. The FFR value was changed from 0.80 to 0.62 athyperemia. This FFR evaluation showed RITA was not functional despite normal flow,so we moved to LAD revascularization. After predilation, we deployed Xience φ2.75 indiameter x 33 mm length.The next is LMT to LAD stenting. After IVUS marking, we deployedXience φ3.5 x 15 mm. After postdilatation, we added dilatation of LCXostium and KBT to LAD/LCX bifurcation(3.5 mm/2.5 mm). Finally, the CAGconfirmed patent LAD stent and no injury.
Finally, the procedure was completed after no injury and stent expansion confirmed by angiography and intravascular sound. Eight months after the intervention, Her LVEF increased to 63% with the improved anterior wall motion. We experienced one case with LAD-CTO protected by the kinked RITA, which was proved to be the culprit of ischemia by FFR evaluation. We often think the ITA kinking is a benign entity particularly if flow seems normal, but as in this case, the kinking in bypass graft should be suspected, appropriately evaluated and treated.