Author + information
- Chanikarn Kanaderm1
Patient Initials or Identifier Number
Relevant Clinical History and Physical Exam
History: 57 years old Thai male, his coronary risk factor is hypertension, dyslipidemia and impair fasting glucose. He underwent PCI to LAD, LCX 13 years ago. 4 hours before admit, He felt angina radiate to chin and shoulder at rest score pain 5/10 and better when taking nitroglycerin sublingual. His son brought him to the general hospital.
Physical examination: Blood pressure 96/56 mmHg, Pulse 72 /minutes full and regular, CVP 4 cm above sternal angle, Chest: No adventitious sound, CVS: No murmur
Relevant Test Results Prior to Catheterization
ECG 12 leads: Normal sinus rhythm, No significant ST-T change
Echocardiography: Good LV systolic function LVEF 62%, no regional wall abnormality is seen, mild mitral regurgitation due to mitral prolapse, LV diastolic dysfunction E/A = 0.7
Chest X-ray: Mild cardiomegaly, no infiltration
Relevant Catheterization Findings
LCA: Significant LAD, LCX lesion
RCA: 90% proximal to mid RCA
We Calculate SYNTAX Score=40, our heart team plan to send this patient to CABG but patient deny.
We start performed an intervention with RCA
Guiding: SAL guiding for more support
Wire: Sion wire (workhorse wire)
Balloon: Predilate with semi-compliance 2.5 * 14 bar, the vessel seems to full dilate
Stent: Stenting at proximal RCA with 3.5 * 33 Firebird2 *14 bar and Stenting at distal RCA with 3.0*29 Firehawk *14 bar
From angiogram seem liked the stent not full dilate so Post dilate with balloon stent 3.0 at overlapping 14 bar was done.
Coronary angiogram was Seen perforate at the proximal stent area.
Treatment: we used microcatheter (Finecross) to auto transfusion to distal RCA for perfuse distal part of the perforated area.
And prolong balloon occlusion at perforate RCA was done more than 30 minutes pass, perforate still persistence.
we had to used Stent graft to covered the perforate lesion, after dilated stent graft with 12 bar, the perforation stilled seen so post dilate stent graft with stent balloon 14 bar again, perforation was stopped.
We plan to have appointed patient to re CAG again next 3 months.
Imaging-guided PCI should be used in the complex lesion.
Avoid post dilate with a semi-compliance balloon.
Prolong balloon perfusion dilatation is the best way to treatment.
Microcatheter with a balloon can use instead perfusion balloon.
The covered stent should prepare in all cath lab.