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Patient initials or identifier number
Relevant clinical history and physical exam
A 68-year-old man with multiple risk factors for CAD(HTN, DM, X-smoker) presented on January 8, 2016 with new-onset CCS class III angina.“Suffocation on minimal exertion”Cardiac catheterization revealed 3-vessel and LM CAD with normal LV function; Syntax score was +33. CABG was recommended but the patient declined the procedure and underwent PCI and total re-vascularization.
Relevant test results prior to catheterization
ABP 140/90 mmhg
Pulse 80 Beats per minute regular equal on both arms.
Chest examination:Harsh vesicular breathing.
The first and second heart sounds were normal.
No lower limb edema.
RBS 130 mg per deciliter.
Hg 12 g per deciliter.
International Normalized Ratio (INR) 1.0.
Creatinine level :1.1 mg per deciliter.
Relevant catheterization findings
LM: Short atherosclerotic vessel that shows ostial long calcified lesion
LAD: Atherosclerotic vessel showing proximal to mid tight long tubular lesion, gives diseased large diagonal branch
LCX: Atherosclerotic vessel showing ostial total occlusion with faint ante & retro-grade flo
RCA: Atherosclerotic vessel with ostial chronic total occlusion with retrograde filling from left system
A radial approach using a left EBU 3.5,6f guiding catheter used to cannulate the right and left coronary artery.
Successful ante grade re-canalization of the RCA using the novel Stabbing wire technique. Successful PCI to RCA using 2 d drug-eluting stents with final excellent result.
Left EBU used to cannulate the LM then Pre-dilatation to LM, LAD lesions.
Followed by wiring the totally occluded LCX followed by predilatation to LCX lesion.
Then Mini Crush technique to LM-LAD and LCX, followed by final simultaneous kissing balloon with excellent results.
PCI to LM disease in the setting of CTO RCA is feasible and should be consider given its low invasiveness in patients at high surgical risk or multiple co-morbidities, but only after RCA re-canalization. In the setting of MVDs, total revascularization should be achieve, in a staged fashion if necessary. Before total revascularization, time, contrast load, radiation dose needed and co-morbidities should be considered. No 2 bifurcations are identical, and no single strategy exists that can be applied to every bifurcation. The more important issue in bifurcation PCI is selecting the appropriate strategy for an individual bifurcation and optimizing the performance of this tech.