Author + information
- Ching-Yuan Tsai1
Patient initials or identifier number
Relevant clinical history and physical exam
This 72 years old. female complained chest tightness radiating to neck for hours. EKG showed infero posterior wall STEMI. Primary PCI performed and infarct-related artery was left circumflex artery. Her LCX was patent again with TIMI-3 flow, after Thrombosuction and stenting. Her left anterior descending artery is blocked at the level of first diagonal branch, Medina (1.1.0). She is okay for 2 days, however chest tightness was told. EKG showed STD in V1-3, so re-angiography was done.
Relevant test results prior to catheterization
EKG1: Sinus rhythm, Q waves in II and III, ST elevation in II, III and AVF, ST depression with R>S in V2-3, ST depression in V1, I and AVL. (before primary PCI)
CXR: Cardiomegaly, bilateral pleural effusion (before second angiography)
EKG2: sinus rhythm, Q waves in II, III and AVF, ST depression in V1-5 and AVL (before second angiography)
Relevant catheterization findings
RCA: proximal 30% stenosis (same as first angiography)
LCX: Patent, no thrombus, TIMI-3 flow (same as the final shot of first PCI)
LAD: Ostium ∼40% stenosis; critical stenosis at first diagonal branch bifurcation, Medina (1,1,0)
1. Engaging LCA with 7FrEBU3.5 (Medtronic, USA); wiring LAD with Sion (Asahi, Japan), D1 with Runthrough floppy (Terumo,Japan).
2. POBA with 2.75 x 20 mm and 3.0 x 20 mm balloon at LAD-m; then IVUS study for vessel size and plaque burden.
3. Axxess (Biosensors, Singapore) was placed into LAD-D1 bifurcation via LAD wire. Then I partially withdrew the device sheath.
4. All distal struts jumped into 1st diagonal branch and the flow of LAD was impeded due to large device size. BP was dropping.
5. Quickly deployed the Axxess stent and remove outer sheath, while distal stent struts still inside the diagonal branch.
6. After flow recovered and BP stabilized, I use 2.25 x 15 mm NC balloon, which was inflated at diagonal branch distal to stent and pulled the balloon in hope to move the Axxess proximally to open it skirts. But the procedure was failed.
7. I tried different balloons like 2.75 x 20 mm or 3.0 x 20 mm pulling from diagonal branch but failed either.
8. I tried 3.0 x 8 mm NC balloon pulling from LAD but failed.
9. I simultaneously pulled 3.0 x 8 mm NC balloon from LAD and 3.0x20 mm from diagonal branch but failed.
10. I put a Biomatrix 2.5 x 14 mm stent through Axxess at LAD to maintain LAD flow, and post-dilated with 3.0 x 8 mm NC balloon.
11. Angiography showed TIMI-3 flow.
1. Be familiar with your device and it is very important to know how to manage if any complication occurs.
2. If struts of Axxess go into only one branch after fully deployment, balloon traction may be helpful sometimes.
3. If not working, bailout stenting in the main vessel will restore the flow.
4. Imagination will help you and be sure to keep calm.