Author + information
- Su Chan Chen1
Patient initials or identifier number
Relevant clinical history and physical exam
This is a 44 year-old male, a current smoker with intermittent chest tightness for three months, CCS III. Chest discomfort was induced during exertion. He was admitted for further survey and evaluation of his problem.
Relevant test results prior to catheterization
Myocardial Persantin scan showed inschemia in the inferolateral wall of left ventricle (21% of total myocardium).
Relevant catheterization findings
CAD done via RRA and showed CAD with DVD (LM: patent; LAD: -M: 40% stenosis; LCX: -P: total occlusion; RCA: -M:total occlusion; with collateral from LAD-D to RCA-D and LCX-D)
We initiated intervention for RCA CTO lesion with bilateral approaches via RFA and RRA. We engaged RCA using SAL 1/7 guiding catheter. A Sion GW could not cross the RCA CTO lesion, hence it was advanced to RCA conus branch. After several attempts, we applied a Progress 200T for antegrade approach and crossed the CTO lesion into RCA-D. We then dilated the RCA-CTO lesion by a Sapphire BC 1.0 X 8 mm BC followed by a Trek 1.2 x 12 mm BC at RCA-D with pressure up to 8 barr. Balloon rupture with contrast staining at RCA-D bifurcation and extended intramural hematoma. A cutting balloon 3.5 x 10 mm BC was inflated at RCA-D to -P with pressure up to 12 barr. The flow of RCA improved but still TIMI 2. A cutting balloon 2.75 x 10 mm was inflated at RCA-D with pressure up to 10 barr. Due to post-POBA dissection type B, a Xience Xpedition 3.5 x 48 mm DES was deployed at RCA-P to -D with pressure up to 14 barr. IVUS showed good stent deposition at RCA-D but mild under-expansion at RCA-P. We then used NC Quantum 4.0 x 20 mm BC to inflated at RCA-P to -M with pressure up to 18 barr. Although there were remained dissection, the final result of RCA was good with TIMI flow 3.
A pin hole balloon rupture could cause coronary dissection, or intramural hematoma (IMH), which results in no-reflow phenomenon. IVUS is useful to evaluate the cause of no-reflow phenomenon. Coronary stent implantation and cutting balloon are helpful to bail out IMH.