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Patient initials or identifier number
Relevant clinical history and physical exam
A 65 years-old diabetic, hypertensive gentleman presented with Unstable Angina. He has past history of Inferior Wall Myocardial Infarction.Patient was not in congestive cardiac failure. His echocardiogram showed mild LV dysfunction with an LVEF of 45% with akinetic and scarred inferior wall.
Relevant test results prior to catheterization
His pre cath profile and echocardiogram was done.
Relevant catheterization findings
He underwent coronary angiogram on day 3 of admission. The angiogram revealed severe triple vessel disease. The RCA was having chronic total occlusion with retrograde filling form left a coronary system. The LAD had tubular 90% tandem lesions. The LCX also had tubular 80% stenosis. He was advised for CABG, but there was refusal from a patient. We subsequently took him for revascularisation of the left coronary system.
As the LAD lesions were technically more challenging we attempted LAD first.We engaged the LMCA with EBU 3.0. Run through intermediate guide wire was passed across LAD lesions. Predilatation of the lesions were performed with Pantera 1.5 X 10 mm and Pantera 2.0 X 15 mm semi-compliant balloon. The LAD was then stented with 2.5 X 33 mm Xience prime distally and 3.0 X 33 mm Xience prime proximally up to the LAD ostium with 3 mm overlap of the stents.The stents were post-dilated with 2.5 X 15 mm and 3.0 X 15 mm NC balloon respectively. TIMI 3 flow was achieved.We subsequently wired the LCX with Asahi Sion Blue wire. The lesion was predilated with 2.0 X 15 mm Pantera Balloon. As we had a stent at LAD ostium and we were not sure whether a long stent would be deliverable or not in LCX we decided to take two shorter stents. A 2.5 X 23 mm Xience prime stent was deployed distally and another 2.75 X 28 mm Xience was deployed at ostio-proximal LCX. The stents were post-dilated with 2.75 X 28 mm NC balloon. Though, TIMI 3 flow was achieved in both LAD and LCX,there was a slight haziness in multiple views at the proximal edge of the LAD stent.It was a probable dissection produced while delivering the LCX stents. Thus, we finally covered from LMCA to LAD with a 4 X 15 mm Xience stent and the ostial LAD (overlapped stented segment) was post dilated with 3 X 15 mm NC balloon. The haziness disappeared and final result was good.He is doing well in follow up. We changed him from clopidogrel to ticagrelor.
Sometimes partial revascularization has to be considered in complex coronary anatomy, specially when patient is post MI and one territory seems to have little viability.In such cases, meticulous planning of a PCI strategy helps in achieving good outcome. Despite every precaution, unexpected complications might occur which has to be addressed promptly. In our case, it was a probable edge dissection in LMCA produced while delivering LCx stent. As it was in distal LMCA we could not take any chance and had to go ahead with LMCA-PCI. Intravascular imaging like IVUS would have helped us in such situations.