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Relevant clinical history and physical exam
A 57-year-old man presented to our hospital with severe chest pain that had persisted for three hours. Emergent coronary angiogram performed and it demonstrated that proximal LAD was totally occluded. After thrombectomy, occluded LAD recanalized and a drug eluting stent deployed in the occlusion. After the stent implantation, a diagonal branch was compromised (‘stent jail’). Although rewiring the occluded side branch was attempted, it did not work.
Relevant test results prior to catheterization
The ECG showed abnormal Q wave in the leads V1 to V3. The echocardiography demonstrated decreased motion of the antero-septal LV. Coronary computed tomography angiography indicated that diagonal branch was occluded although implanted stent was patent.
Relevant catheterization findings
Eleven days after the first procedure, coronary angiography was performed. The DES implanted in the LAD showed good patency. However, a diagonal branch was still compromised and the distal flow of the diagonal branch was provided via collateral channels from the left circumflex.
An EBU 3.75 guiding catheter was engaged via right radial approach. Coronary CT angiogram demonstrated that LAD/diagonal bifurcation was most clearly identified from RAO caudal view in this case. Therefore, penetrating position was marked by IVUS from this view. A GAIA 1st wire was used to penetrate the compromised diagonal branch, however, it did not work due to lack of tip stiffness. A GAIA 2nd wire supported by CRUSADE catheter penetrated the ostium of the compromised diagonal branch and successfully entered the distal lumen. After small balloon (IKAZUCHI 1.2 mm/6 mm) and larger balloon (Lifespear 2.0 mm/15 mm) inflation, occluded side branch was re canalized. Kissing balloon inflation (LAD with 3.0 mm balloon, diagonal branch with 2.0 mm balloon) performed and a good result was obtained. The 12-months follow-up angiogram demonstrated good patency of both vessels.
It is sometimes difficult to rewire the compromised (stent jail) side branch. A rotational coronary CT angiogram gives us a hint about the direction of wire penetration. In this case, compromised side branch was successfully re canalized by using this method.