A 3 in 1 case: A Total Occlusion, Bifurcation and Multi Vessel PCI.

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Benjamin Tao Xiung Lim


1, 1, 1, 1, 1, 1, 1, 1, 1


, Malaysia1
Complex PCI - Multi-Vessel Disease

A 3 in 1 case: A Total Occlusion, Bifurcation and Multi Vessel PCI.

1, 1, 1, 1, 1, 1, 1, 1, 1

, Malaysia1

Clinical Information

Patient initials or Identifier Number


Relevant Clinical History and Physical Exam

Mr SBC is a 60 year old gentleman with no known medical illness. He has been vaccinated against covid. He presented in July 2020 with typical chest pain and shortness of breath. Physical examination was unremarkable and he was diagnosed with NSTEMI. 

Relevant Test Results Prior to Catheterization

His ECG on presentation showed ST segment depression in inferior leads then later had ST depression over leads I, aVL, V2 to V5. Troponin I was85 and creatinine was 86 umol/L. His echocardiography revealed an EF of 52%with mildly impaired systolic function, mild hypokinesia at mid anterior septum and mildly dilated left and right ventricles.

Relevant Catheterization Findings

COROS done showed 2 vessel disease with a smooth LMS, Ostial LAD50-60% stenosis, proximal LAD CTO, Ostial DG1 40-50% stenosis with proximal DG190% stenosis. LCx is non dominant and smooth. RCA is dominant with proximal to mid RCA having 60 - 80% stenosis, RCA crux 70% stenosis with ostial PDA 70-80%stenosis, proximal PDA 70% stenosis. Adhoc PCI was performed for LAD, DG1 and RCA. 

Interventional Management

Procedural Step

Right femoral approach, 7 Fr sheath, EBU 3.5 7Fr engaged to left coronary circulation. Sion blue in fine cross microcatheter advanced into distal LAD.BMW to DG1. Predilate LAD with SC balloon 2.0 x 15 mm at 16 ATM.Predilate DG1 with SC balloon 2.0 x 15 mm at 6 ATM.Predilate LAD with NC balloon 2.5 x 15 mm at 12 - 18 ATM.Predilate DG1 NC balloon 2.5 x 15 mm at 12 ATM.Noted Type A Dissection over mid LAD and Proximal DG1.Stented mid LAD with DES Resolute Onyx 3.5 x 38 mm at 12 ATM.Stented Ostial to Proximal LAD with DES Resolute Onyx 3.5 x 20 mm at12 ATM.Postdilated LAD with NC balloon 4.0 x 8 mm at 16 - 20 ATM.Rewired DG1.First KBI, SC balloon 2.0 x15 mm in DG1 at 16 ATM, NC balloon 3.5x 15 mm in LAD at 20 ATM.Stented DG1 with Resolute Onyx 2.75 x 22 mm at 12 ATM.Done 2nd KBI, stent balloon in DG1 at 12 ATM, NC balloon 3.5mm x15 mm in LAD at 12 ATM.JR 3.5 6Fr engaged to RCA. Sion Blue to distal RPDA.Predilate PDA with NC balloon 3.0 x 15 mm at 16 - 20 ATM.Predilate RCA with NC balloon 3.5 x 15 mm at 20 ATM.DEB to PDA, Sequent please Neo 3.5 x 40 mm at 10 ATM, for 60 seconds.Noted Type A Dissection over PDA post DEB, non flow limiting.Stented Proximal RCA with Resolute Onyx 4.0 x 22 mm at 18 ATM.Postdilated proximal RCA with NC balloon 4.5 x 10 mm at 18 - 20ATMStented RPDA with Resolute Onyx 3.0 x 26 mm at 12 ATM.

Case Summary

TIMI 3 flow, no dissection and no perforation seen on final cine. No significant ECG changes during procedure.No other immediate complications.Procedure was concluded and patient was discharged home well 3days after the procedure.