Author + information
- Jinnu Wen Lin1
Patient initials or identifier number
Relevant clinical history and physical exam
The 86 years-old female was admitted for scheduled CAG study due to effort angina (CCS III ) refractory to medical therapy and positive Thallium scan which revealed stress-induced ischemia in apicoseptal, anteroseptal and inferior walls. CAD risk factors included hypertension. After admission, she suffered from sudden onset of chest pain with cold sweating. The ECG revealed ST segment elevation in precordial leads. She was sent to catheterization laboratory for emergent CAG.
Relevant test results prior to catheterization
ECG : ST segment elevation in precordial leads.
Tl201 myocardial perfusion scintigraphy scan revealed stress-induced ischemia in apicoseptal, anteroseptal and inferior walls.
Relevant catheterization findings
CAD, TVD with heavy calcification
LM distal : 95% stenosis
LAD-ostium : 95% stenosis
Septal channel collateral to RCA
LCX-ostium : 90% stenosis
LCX-PD junction : 80% stenosis
RCA ( dominant vessel) : Total occlusion since ostium
Procedure 1: PCI to LM bifurcation lesion:
We placed IABP for hemodynamic support due to extremely high-risk PCI via left femoral artery approach. From right femoral artery approach, LM was engaged with an EBU 3.0 x 7F guiding catheter. LCX was wired with a Sion blue guide wire and LAD with a Fielder FC guide wire. We did kissing balloon inflation with a 2.5 x 20 mm balloon (Sprinter) from LM-d to LAD, and a 2.0 x 20 mm balloon (Minitrek) from LM to LCX, inflating simultaneously at 10 atm. DK (double kissing) crushing technique was planned for LM bifurcation (Medina 1,1,1) lesion. A 2.75 x 26 mm stent (Resolute Integrity) was positioned in LCX with a minimal protrusion to LM. A non-compliant balloon 3.25 x 9 mm (NC Sprinter) balloon was placed in LM to LAD, preparing for crushing stent. We deployed LCX stent and removed the stent balloon and then inflated the NC balloon in LM to crush LCX stent. We deployed a 3.0 x 22 mm stent (Resolute Integrity) at LM to LAD. We then rewired LCX with a Run through extra floppy guide wire via Crusade micro catheter. Kissing balloon inflation was performed with an NC balloon 3.0 x 12 mm (NC Sprinter) in LM to LAD and an NC balloon 3.0 x 12 mm (NC Sprinter) in LM to LCX, inflating simultaneously at 10 atm. Finally, we used an NC balloon 4.0 x 8 mm for proximal optimization technique, inflated at 18 atm. Final angiography revealed successful revascularization of LM with TIMI 3 flow.
Procedure 2: PCI to RCA CTO:
Months later, she was admitted due to chest pain and dyspnea. Diagnostic CAG revealed patent LM stents. RCA CTO was attempted by antegrade approach first. We put a SAL 1.0x7F SH guiding catheter near the site supposed to be RCA ostium using calcification as a marker. With a support of Excelsior micro catheter, we tried to probe RCA with Fielder FC guide wire but was unsuccessful. We changed the guide wire to Fielder XTR guide wire. After several minutes of struggle, the guide wire successfully reached distal true lumen which was confirmed by contralateral injection. However, any devices such as 1.0 mm balloon (Sapphire II 1.0 x 8 mm ), 1.2 mm balloon (Minitrek 1.2 x 6 mm) or Fine cross micro catheter could not go due to heavy calcification and very critical stenosis. We decided to do Rotablation atherectomy. We tried bare Rotawire wiring by the support of Excelsior micro catheter. After several minutes of struggle, Rotawire successfully reached distal true lumen which was confirmed by contralateral injection. From RCA ostium to RCA-m, the lesion was dilated with 1.25 mm burr followed by 1.75 mm burr for multiple passes. After Rotablation, TIMI flow emerged. We sequentially dilated the lesion with a 1.2 mm balloon (Minitrek 1.2 x 6 mm ), an NC balloon 2.
In summary, the 86 years old female with left main distal bifurcation lesion (Medina 1,1,1) and RCA ostium chronic total occlusion presented with ACS. LM bifurcation lesion was fixed under IABP support which could provide additional hemodynamic support in the setting of high-risk PCI. DK crush technique is a safe and feasible two-stent technique, even in ACS. Rotablator atherectomy is very useful in the setting of CTO intervention with heavy calcification.