OBG

73-year-old male with underlying Bronchial Asthma, referred to us for chest pain, in the setting of newly diagnosed acute leukaemia with severe bicytopenia and leucocytosis. He was initially planned for a diagnostic bone marrow aspiration and aimed for chemotherapy induction later. Upon arrival, he was in respiratory distress, hypoxic with face mask 8L with signs of cardiac failure. He was treated for Non ST elevation Myocardial infarction in failure with concomitant Pneumonia and acute kidney injury 

1) Blood tests attached in image format
2) Serial ECG: SR, ST depression in V2 - V63) CXR: acute pulmonary oedema with right lowerzone consolidation4) Echo: EF 42%, anterior wall hypokinesia, no LVclot 5) CECT Thorax : diffuse bilateral ground-glass appearance. To rule out myelomatous lymphoproliferative changes, chronic lung disease, COVID-196) MSCT CARDIAC: Calcium score 855 Agatston. Moderate to severe stenosis at the proximal and mid segment of LAD and midsegment of RCA

CORONARY ANGIOGRAM :
Right radial approach, Opti torque 5f, very tortuous vessel
LMS: smooth, normalLAD: diffusely calcified, severe stenosis from proximal to mid segmentLCX: non dominant, severe stenosis at proximal and mid segmentRCA: dominant, mild disease
Caudal View - LAD and LCX arteries.avi
Left Anterior Descending - AP view.avi
Right Coronary Artery.avi

Right radial approach / EBU 3.5 / 6Fr, Run through Floppy wire, TELEPORT microcatheter, GUIDEZILLA guide extension, VIPER wire used  RUN THROUGH Floppy wire advanced and wired down LAD, crossed the lesion. Attempted to predilate with SCOREFLEX 2.0/15mm, but unable to cross. Microcatheter TELEPORT introduced for better support. Predilate successfully with MINI TREK 2.0/12 mm at 8 ATM. Then, exchanged with VIPER wire. Proceeded with Orbital Atherectomy with DiamondBack 360 system, run at 80k rpm. Atherectomy done x 7 times sequentially. Re-attempted to predilate with SCOREFLEX balloon, however still unable to cross the lesion. Predilate again with MINI TREK 2.0/12m at 12 atm. Despite predilation with MINI TREK, still unable to pass down bigger sized balloons. GUIDEZILLA II 6FR now inserted and used buddy wire technique with CHOICE PT but still failed to push down bigger balloons. Decided to re-run Orbital Atherectomy DIAMONDBACK at 80k rpm x 5 times sequentially. Finally able to predilate with WEDGE SC 2.5 / 10mm at 10 atm. Finally, deployed DCB SEQUENT PLEASE NEO 2.5 x 20mm at 6 atm for 1 minute to midsegment of LAD. Deployed another DCB SEQUENT PLEASE NEO 3.0 x 20mm at 6 atm for 50 sec at proximal LAD. ST elevation noted transiently during DCB inflation but resolved. Good final results noted. TIMI 3 flow established with no immediate complications
1) Run Through Floppy wired down LAD.avi
2) Re-run of OAS atherectomy device.avi
3) final shot post DCB deployment.avi

We humbly seek to highlight the challenges encountered during this high risk PCI in the setting of acute leukaemia with severe bicytopenia, Patient was co-managed with nephrologist and haematologist support to optimize therapy prior to coronary intervention.He received multiple pre and intra procedural packed cell and platelet transfusions. Radial approach was chosen to minimize bleeding risk. We opted for ad hoc orbital atherectomy in view of heavily calcified vessel. Drug coated balloon strategy was carefully chosen after taking into account risk of bleeding, stent thrombosis, double anti platelet duration, post atherectomy vessel outcome and future chemotherapy induction therapy