Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 75 year-old male smoker admitted with history of effort angina since two years. His symptoms aggravated for last two months despite Guideline directed medical therapy.Hence, he was taken up for coronary angiography with an intent for revascularization.
Relevant test results prior to catheterization
At presentation his blood pressure and heart rate were stable. His electrocardiogram revealed ST coving and biphasic T waves in anterior precordial leads (V2-V6).Echocardiography did not reveal any wall motion abnormality (RWMA) with LVEF= 52%. His haematological and biochemical profile normal and serum creatinine was 0.98 mg/dl. His CRUSADE bleeding score was 20 indicating a low bleeding risk.
Relevant catheterization findings
Coronary angiography via right femoral access revealed a right dominant circulation. LAD totally occluded in Mid segment while RCA having a 90% type B lesion in proximal segment. LCX diseased in distal part including OM1. Ramus intermedius was also severely stenosed in mid segment. In view of Multi-vessel disease, CABG discussed but patient and family opted for multi-vessel PCI. In view of ECG changes corresponding to LAD territory,it decided to revascularize it first.
Extra Back Up guide catheter (Medtronic Vascular, USA) was used to engage left system
LAD wired with Fielder-FC (Asahi Intec,Japan)with multiple attempts and maneuver
However, lesion could not be crossed by low profile 1.0 x 8 mm balloon even after realignment of guide catheter
Subsequently, 1.20 mm & 1.0 mm balloons failed to cross the lesion too.
LAD predilated proximal to Lesion to help balloon advancement but still balloon unable to advance
Buddy wire support taken in diagonal but didn't help either
Anchor balloon support technique unsuccessful
Finally, LAD rewired with an extra support wire -ALL STAR (Abbott Vascular,USA)
This time the 1.0 x 8 mm balloon was able to negotiate the lesion.
Disease segment sequentially predilated with progressively larger (1.25, 1.5 and 2.0 mm) compliant balloons.
Two overlapping DES of 2.5 x 32 mm and 2.75 x 37 mm deployed in LAD
Following stent deployment there was No-reflow and guidewire was also out accidentally
Intracoronary Diltiazem and Adenosine were administered but flow did not improve
Subsequently, LAD rewired and drugs were delivered to distal bed via manually perforated 2.0 x 12 mm balloon catheter.
Final TIMI 3 flow was achieved.
Chronic total occlusion PCI presents multiple challenges for interventionist.Crossing the lesion is by far the most critical step but not always the most difficult as seen in this case. Challenge of balloon advancement is usually mitigated by low profile balloons ,guide catheter alignment,buddy wire support and anchor balloon support. When all of these attempts fails, rewiring should be attempted to remove wire bias and rectify accidental passage of wire into sub-intimal space. Distal drug delivery via manually perforated balloon catheter into distal coronary bed can sometimes help in persistent slow flow/no reflow.