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CASE20200925_006
Complex PCI - Chronic Total Occlusion
Complex PCI of CTO of LCX Using Provisional Stenting Make It Simple
Islam Elsayed Shehata1
Zagazig University, Egypt1,
[Clinical Information]
- Patient initials or identifier number:
A.E.H.
-Relevant clinical history and physical exam:
50Ys old male patient
No family history of IHD
NSTEMI
Hypertensive
Not diabetic
Dyslipidemic
Hemodynamically stable
Pulse: 80 bpm
BP: 130/80 mmHg
LL: No Oedema
JVP: Not raised
Chest: clear
Ht: S1, S2 & 0
Local Exam: free


-Relevant test results prior to catheterization:
T-wave inversion in V4, V5 & V6 of ECG
wall motion abnormalities in lateral LV wall in TTE.
- Relevant catheterization findings:
LCX shows osteal CTO

[Interventional Management]
- Procedural step:
Rt. femoral approach using modified Seldinger technique.
Rt. femoral sheath 6F was inserted
Lt. and Rt. Judkin catheters used for coronary angiography or Lt. and Rt. coronary arteries.
LM: was normal and bifurcates into LAD & LCX.
LAD: was atherosclerotic vessel without significant lesions
LCX: was totally occluded from its ostium with retrograde filling from Rt. system.
RCA: Atherosclerotic vessel without significant lesion
Guiding catheter : JL4
Guide wire: BMW universal introduced distally into LCX and LAD.
Predilatation balloon: introduced over the guide wire into LCX CTO then multiple inflation by compliant balloon (1.5 X 15 mm) inflated at 14 ATM.
Stent: Promus Premiere (3X 20 mm) positioned at ostium of LCX and inflated at 14 ATM with TIMI III flow and no complications.

- Case Summary:
Take home message:
1-Simplify your procedure as much as possible for patient safety.
2-Take your time to put your plan before intervention of CTO lesion.
3-Protect your side branch by another wire during intervention with bifurcational lesions.
4-Start by soft wire for CTO lesion then use wire escalation accordingly.
5-Provesional one stent technique can e used in certain cases of osteal LAD or LCX CTO with consideration to anatomical variations.
6-Be ready to change your plan if any complication occurs.
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