E-Science Station

CASE20210820_001

High Risk PCI of LM Bifurcation with CTO Ostial LCX

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Presenter

Thanawat Suesat

Authors

1

Affiliation

, Thailand1
Complex PCI - Bifurcation/Left Main Diseases and Intervention

High Risk PCI of LM Bifurcation with CTO Ostial LCX

1

, Thailand1

Clinical Information

Patient initials or Identifier Number

Mrs. N M

Relevant Clinical History and Physical Exam

chest pain and dyspnea for 1 day
Recurrent CHF 4 times in 6 month   ESRD  onregular HD  3/week  COPD DCM/ ICM  EF = 22 % with global     hypokinesia , Mild MR ,TR and  AR  refused  to CAG   and only medical  Rx @ CHF clinic 

Relevant Test Results Prior to Catheterization

 BUN  56  Cr  5.94 
Hct 22  %   , WBC 10,200 , plt  100,300  
K = 4.6 
serum albumin 3.3
Trop T  307  ng/L



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Relevant Catheterization Findings

  LM  :  calcification ,90 % distal LM stenosis  LAD : calcification , 80 % ostial LAD,70 %mid LAD stenosis  LCX : calcification , 100 % ostial  LCX  minimal bridging collateral   RCA : non significant stenosis



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Interventional Management

Procedural Step

PCI +  LM  , LAD +   LCX   (if fail LCX   sacrifice of LCX  )heavy calcified  :   Arthrectomy ?    Yes   (but see from IVUS data )                   Temporary pacemaker  Hemodyanamic support ?    Low LVEF + CHF                    only   IABP  available
 RFA  . 7F EBU 3.5 side hole GD
 IABP via LFA , Temp pace vis LFV     for hemodynamic supported 
Predilated with  small balloon 2.0 x15
exchange  to  rota floppy  Rotablator  1.5 burr 180,000 rpm x 3 run , follow by NSE  alpha scoring balloon  3.0 x 13 @ 14atm 
Try  to open LCX ,Pilot 50 +  Finecross failed  Pilot 200 +   Crusade type R double lumen MC  Injection  from  MC ,Seqential dilated with  
Balloon  SC  1.5 x 15  ,Balloon   SC 2.0 x 15  ,Balloon   NC  2.5 x 15 
Stent mid LAD ZES 3.0 x 18  overlapped position  with ZES 3.5 x 24
Position LCX stent and deployed mini crush technique .position LCX stent  with
ZES 3.0 x 14  with Guidezilla  guide extension 
Mini crush  with LM-LAD stent  , rewire and kissing 
POT NC with NC 4.0 x 8  and final angiogram 


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Case Summary


 contrast 100  ml 
 80 minutes procedure time 
 off IABP  6  hr  after  PCI 
Off  ET tube  24 hr  later 
 D/C   3 days after PCI 
  Improve symptoms  , No cheat pain 
  Follow up regular  at CHF clinic   without   readmission    
     for  6  months
    Improve  LVEF  to 42  % 

PCI with LM bifurcation + CTO ostial LCX  is very complex  in high risk patient