Author + information
- Manotosh Panja1
Patient initials or identifier number
Mr S S
Relevant clinical history and physical exam
• A 56 years old male patient has admitted with the features of unstable angina with a past history of Inferior wall Myocardial Infarction 2 years back.
• He was diabetic for 4 years
• He is hypertensive
• EF– 53%
Relevant test results prior to catheterization
• EF– 53%
Relevant catheterization findings
A coronary angiography shows double vessel disease involving LAD (85% narrowing with diagonal ostial lesion with a small caliber) and Left Circumflex with proximal CTO with retrograde co lateral from LAD. RCA has minor disease.
• The conventional approach of CTO with multivessel disease is to treat the CTOfirst followed by the PCI of othe vessels.
• This patient’s LCX CTO had good co-laterals from LAD.
• UnconventionallyI opened the LAD first so that the retrograde to the co-laterals feeding the distal CTO LCX gets a further improvement of flow.
• LAD had 85% lesion crossed with a Floppy wire and jailing od D1 was prevented with another wire
• DirectSENTING of LAD was done with Endeavor Resolute DES.
• ExcellentLAD flow and improvement of collaterals feeding the CTO LCx
• Could able to cross with a Whisper wire and balloon support with great difficulty
• Repeatedly the guide wire was going to the side branch
• After the use of Intra coronary nicorandil, finally, could cross the CTO.
• Sequential balloon dilatation was performed in the whole CTO segment.
• Result after repeated sequential Sprinter balloon dilatation
• It was extremely difficult to tract the 60 mm tapered DES (Proximal 2.75 mm and distal 2.25 mm)
• The guide catheter was dislodged for better co axial alignment to the 90 degrees angulated LCX to tract the long DES while it was half delivered in the LCX
• After post dilation had an excellent result with a long tapered DES
The Biomime Morph from Meryl is a more anatomically acceptable and cost-effective option in diffuse or tandem coronary lesions. There is no question of overlapping stents. It requires less procedural time and provides good clinical outcomes. Ultimately large scale multicentric study with long term follow-up is needed regarding its future.
• 100% proximal CTO of LCX with nearly 90% acute angle with LMCA
• The LCx is a small vessel with a long lesion (60 mm)
• Proximal and distal diameter of the vessel had a gross difference which required 2stents or a long tapered stent (proximal 2.75 mm and distal 2.25 mm)
• LCx had some bending with some minor calcification.