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Relevant clinical history and physical exam
A 70-year old patient was admitted to our hospital for 3 years effort angina. He underwent angiography 2 months ago which showed very severe coronary diseases, he refused CABG and took medicine treatment only. His cardiovascular risk factors included hypertension and hyperlipidemia.
Relevant test results prior to catheterization
The ECG showed avL, V4-6 T wave inversion, the level of liver function tests was normal, creatinine of 109umol/L, BUN 4.88mmol/L, NtproBNP of 115.49pg/ml, TnI of 0.08ng/ml.
Relevant catheterization findings
We reexamined angiography which showed very severe three-vessel diseases, including middle LAD CTO lesion, left main to proximal LAD moderate lesions 50-75% stenosis, a large diagonal branch near the LAD CTO lesion with a 90% stenosis in the ostium, distal LCX CTO Lesion (small), a 75% stenosis in proximal RCA which provided collateral circulation to distal LAD.
1. We selected EBU 3.5 guiding catheter, BMW wire was sent to the vessel D1.
2. Fielder XT wire supported by Fine cross MG could not pass through LAD CTO lesion.
3. Pilot 150 wire passed through LAD CTO with repeatedly trying, then the lesion was dilated with 1.2-12mm and 2.0-20mm balloons.
4. LAD and D1 were checked by IVUS, then we chose to treat the lesions with crush technique.
5. D1 lesion was dilated with 1.2-12 mm balloon.
6. Resolute stent 2.25-18 mm was deployed from distal to middle LAD, then Resolute stent 2.5-24mm deployed from D1 to middle LAD.
7. Balloon crush,then Resolute stent 3.0-30 mm 3.5-24 mm were deployed from middle LAD to LM. After that rewired, kissing and post dilation with NC balloon
8. Angiography showed diffuse stenosis in the distal LAD, IVUS showed severe atherosclerotic lesions, it was dilated with 2.0-20mm balloon, then we used DEB to treat distal LAD lesion and checked IVUS, the result was pretty well.
9. Three months later, the check of angiography showed very good effects for LAD LM and D1.
1. Even some patients cannot accept the treatment of CABG, PCI still can be helpful for them, we should choose right strategy and technique.
2. How to choose CTO wire, from Fielder XT to Pilot 150.
3. CTO with bifurcation Lesion was quite complex, but we still finished PCI procedures step by step.
4. De novo lesions of small vessels can be treated with DEB, the effect of treatment was really good.