Author + information
- Chi-Yen Wang1
Patient initials or identifier number
Mr. SHI, chart number: 560095
Relevant clinical history and physical exam
An 80 years-old gentleman with underlining hypertension, type 2 diabetes experienced acute onset chest tightness for two days. The chest tightness ever happened before. Patient also experienced shortness of breath, cold sweating and jaw numbness sensation. Severe exercise intolerance was also noted. Physical examination revealed coarse rales over bilateral lower lungs and S3 heart sound. Patient admitted for treatment and CAG survey under the diagnosis of ACS of NSTEMI.
Relevant test results prior to catheterization
Following chest X-ray revealed acute pulmonary congestion. ECG revealed possible recent or old anterior and inferior wall myocardial infarction. Elevated cardiac enzyme(Troponin I: 2.61 ng/dl) was noted. Following 2-D echocardiography showed concentric LVH (12, 13 mm ), minimal MR, TR and AR, LV generalized hypokinetic motion, especially apical-to-mid inferior wall akinesia, LVEF was around 35%.
Relevant catheterization findings
Coronary angiography: all vessels were heavy calcified and severe AS change.
LAD: Chronic total occlusion lesion with TIMI 0 distal flow over proximal to middle junction of LAD, receiving mild collateral circulation from RCA
LAD-D1 and D2 branches: 80-85% diffuse stenosis.
LCX: patent, severe AS change and calcification
RCA-proximal: 80% discrete stenosis
RCA-middle: 80% discrete stenosis
RCA Cres: True bifurcation lesion, critical stenosis over PL ostium and PDA ostium
Initially, LAD CTO lesion was approached (EBU 4.0 x 7F) antegradely by a Fielder FC wire supported by a Fine cross. Fielder FC can go into true lumen of distal LAD through the false lumen of CTO lesion. Then the CTO lesion dilated by a 2.0 x 20 mm balloon catheter. However, a large false lumen was created. Parallel wire technique used by another Gaia first wire supported by a Fine cross. We try to rewire into true lumen of CTO lesion. Unfortunately, the Gaia First still cannot go into true lumen after several attempts. Due to possible jail of side branch and vessel perforation, no stenting performed. The procedure was abandoned due to prolonged procedure and much radiation exposure. PCI of RCA was done by two DES stenting and ballooning over distal RCA this time.
We tried to approach LAD CTO again 3 months later. CTO lesion was approached antegradely by a Fielder XT-R supported by a Finecross. Parallel wire technique used again by another Gaia Third wire supported by a Fine cross. Finally, Gaia third can pass through the CTO lesion and go into the true lumen of distal LAD. However, CTO lesion too tight to be dilated in spite of high pressure inflation. IVUS or Stent cannot pass the lesion. We are forced to perform Rotablation with a 1.5 mm burr smoothly. Then the CTO lesion could be opened by further balloon catheter after rotablation. Stenting with a Promus Premier 2.5 x 38 mm over CTO lesion was done. PCI of LAD-CTO was successful. No complication noted.
1. Parallel wiring technique (see-saw wiring technique) is helpful and safe in management of heavy calcified CTO lesion.
2. Plaque debulking through rotablation is risky in calcified CTO lesion but sometimes it is time-saving and necessary.
3. Heavy calcified CTO lesion is always a challenge!