OBM

An 83-year old man Golf player, known case of IHD CABG 1989, under regular follow-up. Has background history of Hypertension and Hyperlipidemia, had an angiogram done 8/2019 for his chronic angina showed CTO LAD, Moderate stenosis at dLMS and ostial LCX, CTO RCA, Patent LIMA, stump SVGRCA & OM. Advised for medical therapy.Still has exertional chest pain although he is on optimal medical therapy.

Blood test: Normal HB and renal profile.Echo: EF 56%, no regional wall motion abnormality seen, thickened AV with Mild AR
echo pre.avi
echo pre short axis.avi

Angiogram:LMS: Moderate stenosis distally, calcifiedLAD: CTO from ostium.LCX: Calcified vessel with moderate to severe ostial stenosis, gives collateral to RCARCA: Sub total occlusion at the proximal segment and CTO distally.LIMA to LAD patent.No graft SVGs seen
patent LIMA.avi

Angioplasty LMS/LCX via RFA 7F sheath under sedation. floppy wire to LCXIVUS cannot cross, predialted with 2.5/15 normal balloon, still IVUS can't cross. decided to use Rotabaltor 1.25 burr @ 140000-150000rpm. Noted slight stain. IVUS showed contained hematoma. vessel size 2.75 distally and 3.0 proximally, calcium cracked with small dissection. Predialted with Non-complaint ballon 2.5/25. stented distal to mid LCX with Synergy 2.75/20. Onyx stent 3.0/28 to LCX/LMS didn't cross. lesion predialted with NC 3.0/15 at high pressure still stent didn't cross, with difficulty Guidezilla catheter passed in with using balloon inflation/deflation technique, then manage to pass the stent to pLCX mid LMS. patient started to have severe pain in spite of sedation. Noted perforation. confirmed by IVUS. decided to put a covered stent. only with Guidezeal manage to pass 3.0/26 covered stent at perforation site. Sealed off. the final result was good. but residual leakage was seen. IVUS showed stent well opposed. no perforation beyond adventitia, decided to leave the residual leakage. Echo showed no pericardial effusion.follow-up echo showed no effusion and maintained EF. post-procedure patient continued to have chest pain which resolved by GTN infusion & ECG showed ST depression which resolved over 2 days with leakage CE.repeat angiogram after one month showed patent stent, small aneurysm. no leakage & echo showed normal Ef of 55-56%. patient started to play Golf without chest pain
post rota2.avi
perofration post 2nd stent.avi

In calcified lesion angioplasty, perforation can occur, so we need to be ready with a covered stent.