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Relevant clinical history and physical exam
A 71-year old man presented with effort dyspnea and exacerbating chest tightness with Canadian Cardiovascular Society Angina Classification (CCS) III for 3 days. His coronary risk factors were hypertension, smoking, dyslipidemia, previous stroke and a history of endovascular aneurysm repair for abdominal aortic aneurysm and left common iliac artery aneurysm in 4 years ago.
Relevant test results prior to catheterization
Echocardiographyrevealed a left ventricular ejection fraction of 34% with hypokinesia of the anterior and inferior walls. Diagnostic coronary angiography tried via right femoral artery but catheter could not be reach to the aortic cusp because of thoracicaorta aneurysm.
Relevant catheterization findings
Diagnostic coronary angiography by right radial artery approach showed chronic total occlusion(CTO) at the mid left anterior descending artery (LAD) with significant stenosis in diagonal OS (Medina classification: 1.1.1.) (Figure A) with grade 2 collaterals from the left circumflex artery (LCX), CTO at the mid right coronary artery (RCA) with TIMI 2 bridging collateral to the distal RCA (FigureB).
The SYNTAX score and EuroScore were 36 and 6. After Heart team activation, transradial coronary intervention was scheduled for the revascularization of the LAD, followed by that of the RCA. With intravascular ultrasound guidance, two Promus Element drug-eluting stents (2.5 x 32 mm and 3.0 x 20 mm) and a Orsiro drug-eluting stent (2.5 x 26 mm) were deployed in the mid to distal LAD and diagonal bifurcation lesions via a 6Fr EBU 3.5 guiding catheter using modified double mini-crushing technique (Figure C). A two Promus Element drug-eluting stents (2.75 x 38 mm) and (2.5 x 34 mm) were deployed in the RCA lesion (Figure D).
The coronary intervention was successfully performed without complications. He was discharged 2 days later after coronary intervention with improved symptoms.Discussion points.
1. How to treat this patient, surgery, PCI or optimal medical therapy?
2. What is the best strategy for CTO intervention in patients with limited access site ?