Author + information
- Hsin Fu Lee1
Patient initials or identifier number
Relevant clinical history and physical exam
This 69 year old gentleman has history of end stage renal disease, type 2 diabetes, peripheral artery disease with left above-knee amputation, hypertension, status colostomy due to sacral bedsore. He presented with resting chest pain and diaphoresis accompanied with progressive dyspnea for one day. He was transferred to our emergency room. Tachycardia and blood pressure of 85/45 mmHg were recorded. Bilateral lung crackles were heard, and peripheral limbs were cold.
Relevant test results prior to catheterization
Laboratory data showed elevation of Tn I 36.5ng/mL and BNP 1695 pg/mL, and mild anemia (hemoglobin: 10.9 g/dL). Chest X ray revealed cardiomegaly with bilateral lung edema. ECG showed atrial fibrillation with rapid ventricular response and ST segment depression over precordial leads. Cardiac echo found left ventricular ejection fraction 35% with global hypokinesia, mild mitral regurgitation, and dilatation of left ventricle and atrium.
Relevant catheterization findings
Coronary angiography showed multiple stenosis of coronary arteries including distal left main (LM), left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). Special attention should be paid for severely calcified vessels and extremely angulated bifurcation of LAD and diagonal coronary arteries.
Intra aortic balloon pumping catheter was placed before coronary intervention. For his poor LV systolic function and cardiogenic shock, total revascularization in the single procedure was planned. LCX was implanted with one drug eluting stent (DES) at middle portion first, but dissection at proximal LCX after prior stent delivery was complicated. Therefore, bail-out stenting with 2nd DES was performed. For LAD/D bifurcation intervention, balloon pre-dilatation with 2.0 mm diameter of semi-compliant balloon was performed with 10 atms to prevent from much dissection which may lead to difficult wiring for D branch. With adequate back-up support of 7F EBU 4.0 guiding catheter, we could advance Crusade catheter with reversed wire through calcified and inadequate preparation of LAD to distal portion, and successfully performed revere wire technique to advance the guide wire into diagonal branch. After successful wiring for LAD and D branch, aggressive balloon pre-dilatation were done for them thus leading to severe dissections. The 2 stent technique with DK Crush technique instead of Culotte technique was performed to the bifurcation, in which DK Crush technique does not need to rewire the dissected LAD. After bifurcation stenting, IVUS was used to evaluate LAD, LCX, and LM. The following procedure was doing stenting from LAD to LM. Distal RCA was also opened and implanted with a stent.
With the thickness of the shaft of Crusade micro catheter and swan-neck part of guide wire, a luminal space is needed for passing through the lesions and for torquing the reversed wire. We reported the present case showing the feasibility of performing Crusade-micro catheter assisted reversed wire technique for heavily calcified and stenotic lesions for an ACS patient with cardiogenic shock.