Complex PCI - Multi-Vessel Disease
Conquering the Tough Odds
Afrah Yousif Haroon1, Hafidz Abd Hadi1
National Heart Institute, Malaysia1,
A 70 years male knowncase of hypertension, hyperlipidemia & case IHD, PCI pLAD & RCA 2019, recentNSTEMI coronary angiogram showed distal LMS stenosis, ostial LCX and LAD severedisease & ISR LAD & RCA. Counselled for CABG, but not keen, referred tous for high risk multivessel angioplasty angioplasty. Echo showed EF 41%. LAD LMS angio vedio.avi RCA angio Vedio.avi
Tortous RCA, difficult witing, managed to pass prediltationballoon after straightening the artery with guide plus and grand slam wire.Predilated with Minitrek 2.0x 10, IVUS showed Severe In-Stent Restenosis,old stent is under sized,2.5 stent. Vessel size 3.0-3.5 distally, heavy plaqueburden.Predilated with Wedge NC 2.5 x 10, & NC Emerge 3.0 x 8mm at ostium Stented in stent withSynergy 3.0 x 48mmPostdilated with NC Emerge 3.5 x 12mm & 4.0/12 proximally with baloob anchor manage to wire vedi.avi stenting RCA vedio.avi
RFA7F sheath changed to long arrow sheath 7F
IVUSshowed Left Anterior Descending - Severe In-Stent Restenosis, vessel size 3.0 -35 proximal LAD. LCX - Diffuse severe disease from ostium to distal vessel size3.0. Left Main Stem - Vesselsize 5.0, moderate disease, distal segment.
Predilatedwith LCX to LMS and LAD with Scoreflex2.5 x 15mm then Predilated with EmergeNC 3.0 x 15mm. Stented distal – pLCX withCRE 8 3.0 x 46. Stented pLCX to LMS with CRE 8 3.0 x 12mm at proximal segment with NC 3.5 x 15mm crushedLeft Circumflex stent, Rewired Left Circumflex, open stent strut with Sapphire2.0 x 15mm, POT Left Main Stem withNC 4.5 x 8mm, 1st Kissing LAD 3.0 x15mm and LCX 3.0 x 15mm.
StentedLAD to LMS with CRE 8 3.5 x 20mm, 2nd Kissing - LAD 3.6 x 15mm and Left Circumflex 3.0 x15mm, POT Left Main Stem withNC Emerge 4.5 x 8.
UpsizedLAD stent with 4.5 x 8mm NC,Postdilated Left Main Stem with Emerge 5.0 x 8mm, IVUS post All stent well opposed, no dissection stenting pLCX vedio.avi stenting LAD LMS vedio.avi final lms.avi
Coronary artery tortuosity is a common angiographic finding and has been associated with difficulty in passing wire, balloon and stents and also with adverse events after PCIThe use of adjuvant stool such as super stiff wire, arrow sheath to over come femoral tortuosity and guideliner and grand Slam wire for coronary .The usefulness of intravascular imaging to understand ISR .