Author + information
- Debdatta Bhattacharyya1
Patient initials or identifier number
Relevant clinical history and physical exam
A 64 years-old male history of hypertension, diabetics, presented with chest pain on physical exertion. He was a non smoker and with positive family history of ischemic heart disease. There was no prior history of myocardial infarction. On physical examination his body weight was 64 Kg with a BMI of 20, Pulse 60 beats/min. Blood Pressure 140 /90 mm Hg with no signs of heart failure. Chest was clear, heart sound was normal with no cardiac murmur.
Relevant test results prior to catheterization
ECG : Normal Sinus Rhythm
Echo - Concentric LVH, No RWMA. EF-69 %
Hb : 14.1 gm/dl
FBS : 80 mg/dl
Creatinine : 1.0 mg/dl
LDL : 130 mg/dl
Triglyceride : 180 mg/dl
HDL : 30 mg/dl
HbA1C : 7.0
Relevant catheterization findings
Angiography reveled bifurcation lesion in LAD and D1. Good LV function. EF 69%. 90 TO 95 % stenosis in Proximal LAD. 70% stenosis in proximal segment of D1 and 90% of stenosis in mid segment of D1. LCx normal. Left main normal. RCA non dominant and normal.
The 7F XB 3.5 guide was used. Both LAD and D1 were wired by using Run Through intermediate wire. LAD pre dilatation was done by using NC Trek 3 X 12 mm at 12 ATM and D1 was pre-dilated with 2.75 X 12 mm NC Trek at 12 ATM. D1 stented with 2.75 x 30 mm Endeavor Resolute at 10 atm. POBA / 1st Crush was done by putting 3 x 12 mm NC balloon at LAD. D1 was re-crossed with the same wire. LAD was stented by using 3.5 x 38 mm Endeavor Resolute at 10 atm. Final Kiss was done by using 2.75 x 12 mm NC trek at D1 and 3 x 12 NC trek at LAD. POT was done by using 3.5 x 12 mm balloon in LAD. Further, stenting was done with 4 x 15 DES to the LMCA. IVUS pull back Atlantis Pro catheter (Boston Scientific 40 Mhz) study was performed from D1 to LAD and Distal LAD to LMCA.
Follow up was done after 6 months and angio showed patent stents in LAD, D1 and LMCA with no evidence of restenosis.
DK crush, if done properly, gives excellent ostial coverage of the SB with good CSA at the ostium. IVUS guidance helps in optimize the result of the SB particularly at the ostium where maximum re-stenosis happens when using 2 stent strategy. Such accuracy is not always possible by angiography alone . IVUS, also ensures accuracy of the stenting in the main vessel and proximal optimization (POT).
Our initial satisfaction at the end the end result of the index procedure was borne out by the excellent follow up at the end of 6 months when repeat angiography has been carried out.