Author + information
- Daisuke Miyawaki1
Patient initials or identifier number
Relevant clinical history and physical exam
The patient in our case was a 49-year old male who had undergone percutaneous coronary intervention (PCI) in the right coronary artery (RCA) and left anterior descending (LAD) coronary artery. He had chronic kidney disease (CKD) in the stage G4A3. He admitted to our hospital complaining of worsening exertional chest pain.
Relevant test results prior to catheterization
Electrocardiography showed atrial fibrillation, complete left bundle branch block and flat T waves in the chest leads of V5 and V6. Echocardiography demonstrated diffuse mild hypokinesis in the left ventricle. And left ventricular antero-septal wall showed reduced uptake of radioisotope in the myocardial perfusion scintigraphy. Renal dysfunction was indicated by serum CRE 3.11 mg/dL.
Relevant catheterization findings
Coronary angiography demonstrated stenotic lesions in the proximal RCA and the mid LAD coronary artery. Besides, there was an in-stent chronic total occlusion(CTO) in the distal LAD coronary artery which was perfused with the collateral arteries from RCA.
Considering his renal dysfunction, we had to minimize the consumption of contrast medium. For that purpose, we planned elective PCI for each artery. In the initial session, we treated stenotic lesion in the RCA. Under intravascular ultrasound (IVUS) guidance, we deployed a drug-eluting stent (DES) with no contrast medium. We confirmed favourable blood flow with angiography using only 4 cc contrast medium. Preparing for the next session of treating CTO lesion in the LAD coronary artery, we confirmed collateral route by tip injection from a micro-catheter with 2cc contrast medium.
In the second session, we first deployed a DES at the stenotic lesion in mid LAD coronary artery under IVUS guidance using no contrast medium. Next, we successfully advanced ultimatebros 3 guide wire through the CTOlesion to distal LAD artery. Tactile feeling of guide wire passage and comparison with the control image of selective angiography in the previous session made us believe the guide wire is situated inside the vascular lumen. Then, we inflated drug-coated balloon after lesion preparation with a scoring balloon. We confirmed good blood flow with 6cc contrast medium injection.
Contrast-induced nephropathy (CIN) frequently occurs in CKD patients who undergo PCI, and CIN is often associated with increased mortality.To prevent CIN, it is important to minimize the volume of contrast medium to be used. We demonstrated successful coronary intervention for multiple lesion including chronic total occlusion with minimum contrast medium.