Author + information
- Liang-Ting Chiang1
Patient initials or identifier number
Relevant clinical history and physical exam
This 75-year-old male non-smoker had intermittent angina, CCS-2, and dyspnea on exertion, NYHA Fc 2-3. He had hypertension, DM, and hyperlipidemia.Physical examination found minimal basal rales before medical treatment adjusted. Heart sound was regular without significant murmur.He was admitted to receive planned coronary angiography for probable ischemic cardiomyopathy.
Relevant test results prior to catheterization
Echocardiography showed poor LV contractility (LVEF 24% by area length), mild MR and TR.
Thallium scan showed moderate-to-severe stress-induced ischemia and mixed scar, especially over anterior wall.
Relevant catheterization findings
Coronary angiography through left radial artery showed as followed:
LM : Patent
LAD: proximal 95% stenosis with tortuous route, mid total occlusion (CTO), with bridging collaterals
LCX: large vessel size, OM4 75% stenosis
RCA: Irregularity, without significant stenosis, wiht collateral to distal LAD
Engage 6Fr EBU 3.5 to left coronary artery, via left radial approach.
2. Try wiring Sion with Corsair. Due to the proximal sharp turns, Sion was easily stuck in the plaque or sliding into the septal branch.
3. Try to wiring Ultimate Bro 3 with Corsair. With stiffer shaft, the curved tip could be pushed through the turns. However, wire could not support Corsair to cross the proximal lesion, than Ultimate Bro 3 could not be re-shaped for crossing the CTO. Subintimal tracking happened
4. Re-wiring Ultimate Bro 3 to diagonal branch before more vascular injury, and pass Corsair cross the proximal lesion. After, carefully adjusting repeatedly, the Corsair could finally face the proximal cap of CTO
5. With good support and co-axial direction of Corsair, Gaia 2nd finally crossed the CTO with success
6. Balloon dilatation to LAD with Ikazuchi 2.0x15mm to 8atm 7”
7. Wiring diagonal branch with Sion Blue, for protection
8. IVUS was performed for evaluating the landing zone of stents
9. Resolute Integrity 2.5 x 30 mm was deployed to mid-LAD with 10 atm 5”
10. Resolute Integrity 3.5 x 26 mm was deployed to proximal-to-mid LAD with 10 atm7”, with diagonal branch compromised.
11. Diagonal branch was re-wired and IVUS was performed again.
12. Kissing balloon technique was performed with Ikazuchi 2.0 x 15 mm in LAD-Diagonal with 6 atm 15“and NC Sprinter 3.0 x 15 mm in LAD with 12 atm 15”
13. Post-stenting dilatation was performed with NC Sprinter 3.0 x 15 mm to mid-LAD up to 12 atm 8”
14. The final flow was good
The proximal tortuous route was not easier than CTO. Multiple gentle techniques were used before having a mess. Controlled damaged was important for antegrade approach. Due to the proximal tortuous part, retrograde approach would face same problem, and would not be the solution. Careful planning for approach, side-branch use, wire selection was basic, but important. This is a case looking great for trying, but actually with much difficulties. It would remind a interventionist more thoughtful, not only to the CTO lesion.