CASE20210827_006

IVUS Guided and IVL Assisted Successful Percutaneous Coronary Intervention of Densely Calcified LAD and Successful Management of Stent Fracture

By , , , ,
like off

Presenter

HARSIMRAN SINGH

Authors

1, 1, 1, 1, 1

Affiliation

, India1
Complex PCI - Calcified Lesion

IVUS Guided and IVL Assisted Successful Percutaneous Coronary Intervention of Densely Calcified LAD and Successful Management of Stent Fracture

1, 1, 1, 1, 1

, India1

Clinical Information

Patient initials or Identifier Number

586869

Relevant Clinical History and Physical Exam

76 year old gentleman admitted with history of chest pain on exertion (CSA II) since 6 months. Pain was central and compressive type, non radiating. He was a known case of hypertension and was recently diagnosed with DM II.BP- 160/70mmHg, HR- 62/min, RR- 20/minCVS- S1S2 normal, no murmurs audible.RS- Normal Vesicular Breath Sound b/l, no added sounds

Relevant Test Results Prior to Catheterization

ECG- RBBB2D ECHO- Normal chambers dimensions, trivial MR, mild AR, no regional wall motion abnormality, normal LV systolic function (EF-63%), GLPS average -24.6Hb- 9.4 g/dlPlatelets- 2.0 lakhsHbA1c- 7.3%S.creatinine- 1.2 mg/dlBUN- 12 mg/dlCholesterol- 80 mg/dlTriglyceride- 76mg/dlLDL- 54 mg/dl

Relevant Catheterization Findings

LM normal, bifurcating into LAD & LCXLAD is a type III vessel and is severely calcifiedBefore the origin of D1 it had 60-70% lesion followed by 95% lesion. At the origin of D1 90% lesion in LAD (medina 1,1,0) LCX continue as major OM which was branching into superior and inferior branch. inferior branch had ostial 60-70% lesion. Other OM branches are free of disease.RCA is a dominant vessel with mild disease in mid segment, PDA had 60-70% lesion.

3.mp4
4.mp4
6.mp4

Interventional Management

Procedural Step

-7 F BL 3.5 guiding (Terumo, Japan) used to hook left coronary artery and Runthrough wire (Terumo, Japan) used to cross the lesion in LAD.-Predilatation done with 1.5x10mm SC balloon (Terumo, Japan) followed by 2.0x12mm (Terumo, Japan)-IVUS run showed 360 degree calcification in pLAD with MLA of 1.90 mm-IVL 3.0X12mm balloon (Translumina, USA) used to give 6 cycles of shock-Distal LAD lesion stented with 2.0x18mm DES (Medtronic, USA), mid LAD stented with 2.75x18mm DES (Medtronic, USA) and proximal LAD stented with 3.0x18mm DES (Medtronic, USA)-IVUS showed MLA of 3.63mm2 with under expansion of stent in the mid segment. Calcified area showed increase in the MLA from 1.90mm2 to 7.24mm2  -Post dilatation done with 2.75x8mm NC balloon (Terumo, Japan)-Stent fracture was noted in the near the overlapping of mid & distal stent. Hence it was stented with 2.75x8mm DES (Medtronic, USA)-TIMI III flow achieved with no complications.
9.mp4
11.mp4
14.mp4
POST POBA.wmv
16.mp4
24.mp4
28.mp4
30.mp4
32.mp4
POST STENTING.wmv
33.mp4
35.mp4
37.mp4
38.mp4
40.mp4

Case Summary

- Among the various techniques to treat calcified lesions (rotablation, laser atherectomy, high pressure balloons etc) IVL is the simple technique to learn and has great end results with very low complication rate.- Imaging helps to characterize the lesion and helps in planning intervention.- Stent fracture should be covered with other stent to prevent restenosis.