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Patient initials or identifier number
Relevant clinical history and physical exam
A 58 years-old female with diabetes and hypertension presented with exertional angina. there was past history of AWMI. On examination she weighed 62 Kg with BMI of 21 kg/m2. Pulse was 71 bpm and regular. Her BP was 130/80 mmHg. Chest was clear. Pulse 58 beats/min. There was no evidence of any valvulopathies.
Relevant test results prior to catheterization
ECG: Deep T wave inversion in leads V1 to V6
ECHO: Hypokinetic apex, mid anterior wall, other walls were contracting normally
Moderate LV dysfunction with LVEF : 40%, Grade I diastolic dysfunction.
Hb: 12.1 gm/dl
Creatinine: 1.0 mg/dl
FBS: 140 mg/dl
HbA1 : 7.4
Relevant catheterization findings
CAG : Triple vessel coronary artery disease
LMCA : Normal
LAD : Type III vessel, shows critical 90% stenosis in the mid part after D1 followed by sub total occlusion from mid part after D2 with faint antegrade flow. There is filling of LAD via collaterals from right system
LCx : Minor disease
RCA : Dominant, shows 30% stenosis in the mid part followed by 80% tubular stenosis in the mid-distal junction
6F XB 3.5
Guiding wire : Stabilizer super soft. Pre-dilatation done into the proximal mid LAD with mini trek 1.5 X 6 mm balloon at 16 ATM. another pre-dilatation done into the mid distal LAD with pantera 2 x 15 mm balloon at 8 ATM. POBA was done into distal LAD with pantera 1.5 x 15 mm balloon at 18 ATM. IVUS motorized pull back study was done by using Atlantis Pro Catheter (Boston Scientific 40 Mhz) from distal to proximal LAD onto LMCA. Further pre-dilatation was done into the mid LAD with NC trek 2.5 x 12 mm balloon at 18 ATM. Stenting was done into the mid LAD with Supraflex 2.75 X 40 mm stent. post dilatation was done with 3 x 12 mm NC pantera balloon at 14 ATM. Repeat IVUS motorized pull back study was done by using Atlantis Pro Catheter (Boston Scientific 40 Mhz) from distal to proximal LAD onto LMCA. Another post dilatation was done into the stented LAD segment with Pantera Leo 3.5 x 15 mm Balloon at 15 ATM. Final TIMI III flow was achieved.
QCA invariably underestimates the diameter of the LAD in diabetic Indian females with severe diffuse coronary artery disease. PCI guided by angiography alone results in under-sizing and under-expansion.Small disease in Indian diabetic females is due to high plaque burden and vessel shrinkage rather than inherently small calibre vessels, and the routine use of IVUS would be beneficial in optimizing stent sizing and stent optimization and is likely to improve long term outcomes in this subset.