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Patient initials or identifier number
Relevant clinical history and physical exam
A 65 year-old woman presented with recurrent typical chest pain (Canadian Classification Score 3). There was progressive worsening symptom accompanied with significant exertional dyspnea. She had diabetes mellitus with no history of previous myocardial infarction. She had no hypertension, dyslipidemia, nor smoking history. Blood pressure: 110/70 mmHg, heart rate: 74 bpm, respiratory rate: 22 tpm, and positive gallop sound in heart auscultation.
Relevant test results prior to catheterization
Electrocardiogram showed sinus rhythm with anterior old myocardial infarction. Echocardiogram revealed anterior, anteroseptal, and anterolateral hypokinesia with reduced ejection fraction (42%)
Relevant catheterization findings
Coronary angiography examination showed ostial left main coronary artery (LMCA) occlusion. The lesion considered chronic process due to good protective collateral blood supply existing from right coronary artery.
The patient refused CABG, therefore, PCI were performed. Guide wire Run through NS hypercoat selected to cross the occlusion lesion because the micro channel was still visible at the cto lesion. Several efforts were attempted to penetrate the proximal cap because the guiding catheter could not engage properly hindered by ostial LMCA lesion. After guide wire succeeded to cross the lesion several predilatations were performed at ostial LMCA to LAD. At this point the result still not satisfied due to the lesion was calcified. Drug eluted stent (DES) 3.0 x 13 mm deployed at ostial-distal LMCA to give a way to guiding catheter to engage properly at the ostial LMCA. After stent deployment, apparently the LAD has diffuse lesion, and the guide wire was not at distal LAD. Rewiring to distal LAD then performed followed by several predilatation at ostial to mid LAD as preparation before stent deployment. Finally DES 2.75 x 28 mm deployed at ostial to mid LAD overlapping with the previous stent. Procedure finished without complication, with the result of TIMI flow 3.
It has been reported a successful percutaneous coronary intervention of ostial LMCA CTO. PCI on LMCA CTO is very rarely performed, because it has a strong indication for bypass surgery, even guidelines mention it is harmful to perform PCI. It is a very challenging case because every step was difficult, starting from guiding catheter engagement, penetration and advancement of guide wire to stent deployment. In spite of the challenges, we succeeded to cross the lesion using only workhorse guide wire without sufficient back up of the guiding catheter which was improperly engaged, followed by stent deployment.