Author + information
- Chi-Wei Wang1
Patient initials or identifier number
Relevant clinical history and physical exam
The 78 year old previously healthy male was admitted due to DOE and bilateral edema for 2 months, Above symptom progressed in recent two months. Heart failure diagnosed in the other hospital. Physical exam showed S3 gallop, elevated jugular pressure 13 cm H2O.
Relevant test results prior to catheterization
CXR showed cardiomegaly
ECG showed poor R wave progression
Echo: LVEF: 19% ,the LV proximal 1/2 anterolateral, proximal 1/2 anterolateral and IVS to apex showed akinetic motion.
Relevant catheterization findings
LM : Severe AS change, at least 50% stenosis in the body
LAD : diffuse severe AS change with heavy calcification
LAD: Long CTO without any stump
LAD-M-D: receives collaterals from PDA
LCX : Diffuse severe AS change with heavy calcification
LCX-M: Segmental CTO, also without visible stump
RCA : Long large dominant vessel, supplies dominant PAD and PL branch
Total syntax score was 72. The initial strategy was hybrid therapy with robot-assisted CABG for LCA and protected stenting for RCA lesions. PCI for RCA was approached by SAL guide under distal BST filter placement. The RCA-M was successfully scaffolded with a 2.75 x 12 mm DES with some difficulty and some chest pain during the procedure. Patient’s symptom improved a lot after the PCI but regret surgical bypass for LCA lesions. Therefore, PCI for LAD intended one month later with a retrograde approach using a SAL 1.5 x 6Fr guide in RCA. The septal collateral could be tracked by a Sion but it had to be tracked by a Fine cross, Corsair, Fine cross sequentially. The heavily calcified CTO segment successfully penetrated by an Ultimate 3 which was further advanced into aorta.After wire externalization, the CTO segment was sequentially dilated by a 1.5 mm x 20 and 2 x 30 mm BC. Due to diffuse disease, small vessel caliber and no stenting possible, the LAD CTO treated with 2 x 20 mm BB DCB only, but the final flow was good. CAG FU was done in three weeks and found patent LAD with good flow despite critical residual stenosis at the ostium. The lesion was antegradely rotablated with a 1.25 mm and a 1.5 mm burr, dilated with a balloon and scaffold with a 2.25 x 26 mm DES. The LM to LAD-P supplemented by another 2.75 x 16 mm DES. After post dilatation, the final angio showed very pleasing results.
In conclusion, modern PCI concepts and techniques were used in treating this particular case with very high Syntax score,including distally protected coronary stenting, retrograde PCI for a CTO without stump and with acute angulation from the parent vessel, DCB use when stenting not possible in vessel with very small caliber, rotablation for heavily calcified vessel and ostial lesion before final DES.