Author + information
- Johan Senihardja1,
- Rizki Francis Pandelaki1,
- Benny Mulyanto Setiadi1,
- Monique Priscilla Fransiska Rotty1,
- Bambang Budiono2,
- Janry Anton Pangemanan1 and
- Agnes Lucia Panda1
Patient initials or identifier number
Relevant clinical history and physical exam
Patient admitted due to chest pain about 2 weeks ago. The patient felt like tightness in left side of her chest. It was felt while doing moderate activity with duration about 5 minutes or less. A week ago, patient also admitted to private hospital due to the same complaint. Having done the diagnostic angiogram, the result wastwo vessels disease and patent stent at LAD. Patient had history of PCI in 2009, consumed anti platelet agent, and statin regularly.
Relevant test results prior to catheterization
ECG showed that there was T inverted at V4-V6 indicating ischemic process at anterolateral segment.
Relevant catheterization findings
From angiogram performed just one week before, the result was that:
Left main : Normal
LAD : Stenosis 30% at mid LAD and patent stent at mid LAD
Intermediate : Stenosis 90% in proximal intermedius brach
LCX : Stenosis 90% in ostial LCx, stenosis 80% at mid LCx, and total occlusion lesion after OM2
RCA : Stenosis 70% in proximal RCA
The PCI to LCX lesion was done using trans femoral approach. a 6Fr JL3.5 guiding catheter was inserted to engage left coronary ostium. A 0.014“(ASAHI SION) wire inserted to LCX artery, but failed the tight CTO lesion. A 0.014” (Filder XT) wire successfully crossed the lesion. A 1.2 x 6 mm(Ikazuchi) advanced to pre-dilate the lesion, but failed to cross the tigh tlesion. Then a 0.014“ (ASAHI Gaia First) used as mechanical thrombectomy using parallel wire. The wire only could pass to the mid of the lesion. The operator did not have a good supporting guiding catheter. Either Therefore, the operator changed the guiding catheter using 6 French CLS 3.5. The cine was performed, showed there was spiral dissection of coronary artery at distal LCX.The patient did not complain any symptoms nor was ECG changes observed due to this complication. The operator continued the procedure calmly. A 0.014”(ASAHI SION) wire used to prevent further complication. It crossed successfully through the true lumen. A serial balloon used to predilate the lesion; they were a 1.2 x 6 mm (Ikazuchi) balloon, 2.0 x 25 mm (Ikazuchi) balloon, and a 2.25 x 15 mm (Ikazuchi) balloon, respectively. Eventually, a 2.25 x 16 (CRE8)stent used to treat the complication and the STO lesion. The final angiogram showed good result with TIMI 3 Flow without any complication and symptom. The PCI procedure, then continued to treat ostial LCX and RCA, it went smoothly.
The PCI procedure for subtotal occlusion is challenging. The difficulty is as difficult as dealing with CTO lesion. We should never underestimate the STO lesion.Having a problem in passing the smallest balloon, it could be very frustrating.A mechanical thrombectomy using parallel wire is one of the options. However,we have to be preparing for dealing of any complication, such as dissection or perforation. From this case, we can learn, despite of occurring the spiral dissection, not always give the symptoms nor worsening the patient status.Therefore, we should keep calm and are be able to maximize the “limited time”. Most of the dissection cases can overcome by putting a stent at that area.