HO

A 69 years old male with a chief complaint of dyspnea on effort since the last 3 months, he also felt angina mostly during moderate activity. He had a history of STEMI anterior without revascularization 4 months earlier in July 2020. His risk factors were hypertension and ex-smoker. His physical examination was unremarkable.

ECG showed sinus bradycardia with heart ra59x/mins, Q wave at infero-anteroseptal. Persistent ST elevation at V4-V5.Echocardiography revealed reduced LV systolic function with EF 34%, hypo-kinetic at mid-basal anteroseptal, apico lateral.Diagnostic CAG showed 3VD with LMS + CTO LAD ( SYNTAX SCORE 51), turned down by surgeon due to not suitable for graft.


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LM: Severe calcification at distal, diffuse stenotic at osteal-distal with maximum stenosis 70-80%, LAD: Severe calcification at proximal; CTO at proximal, distal had flow from contralateral (Rentrop 3), LCx: Dominan, moderate calcification at proximal, subtotal stenosis at osteal, RCA: small calibre, diffuse stenosis 40-50% at ostial-proximal.
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After successful IABP insertion, we planned for PCI CTO LAD with antegrade approach. We crossed the CTO lesion with Fielder XT-A. Pre-dilatation gradually upsized with SC balloon 1.25/20 mm, 2.0/20 mm and 2.5/20 mm. DES Promus Premier 2.5/28 mm was implanted at 11 atm at distal-proximal LAD. Then we continued with LM bifurcation stenting using DK Crush technique. LCx pre-dilatation with SC balloon 2.5/20 mm and NC 3.5/15 mm. DES Firehawk 3.5x23 mm was implanted at 11 atm at proximal LCx with slightly protruding to LM. Crushing the stent was done with NC 3.0/15 mm at 16 atm. Successfully re-crossing wire at proximal strut stent LCx. First KBI was done with NC 3.5/12 mm (LM-LAD) and NC 3.0x15 mm (LM-LCx) at 8 atm. LM-LAD stenting with DES Firehawk 3.5x38 mm at 16 atm at proximal LAD-osteal LM overlapping with the first DES. POT LM was done with NC 4.0/12 atm at 12 atm.  Re-crossing wire at proximal strut stent LCx then delivery device with balloon anchoring technique using SC 2.0/20 mm at 6 atm at LAD.  Additional post dilatation LCx was needed, gradually upsized with SC 1.25/15 mm, 2.0/15 mm and NC 3.25x15 mm. Final KBI was done with NC 3.5/12 mm (LM-LCx) and stent balloon 3.5/23 mm (LM-LAD) at 10 atm. Re-POT  LM with NC 4.0/12 mm at 20 atm. IVUS evaluation showed well-expanded and well-apposed of all stents and no edge dissection was seen. Final angiography showed TIMI 3 flow with good result. One-week clinical follow-up revealed no more chest pain and shortness of breath.

This patient had a severe coronary artery disease and been turned down for surgery revascularization, so high-risk PCI procedure with IABP support was commenced. DK crushed technique was chosen with IVUS guidance due to good outcome from the latest trials for this technique. This CHIP procedure provides a satisfactory result with favorable clinical outcome.