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

T-wave inversion in V4, V5 & V6 of ECG

wall motion abnormalities in lateral LV wall in TTE.

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.

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.