MRD

A 73-year-old man, with underlying hypertension, dyslipidemia & chronic kidney disease, admitted to peripheral hospital for NSTEMI with Cardiogenic Shock, was then transferred to us for inpatient coronary angiogram once he was stable & extubated. Angiogram showed tight stenosis distal left main (Medina 1, 1, 1) with high OM1, and normal RCA. IABP was inserted & referred to surgeon for urgent CABG, however, was declined due to poor EF 23%. He was then planned for high risk PCI.

Echocardiogram, 1st October 2020:EF 23%, global severe hypokinesia, dilated LV, TAPSE 2cm, mild MR
Viability Study, 6th October 2020:Large area of transmural infarction at distal LAD.Moderate area of non-transmural infarction at proximal-mid LAD and RCA/LCx territories.

Coronary Angiogram, 7th October 2020:LMS: tight stenosis distal LMS, Medina 1, 1, 1LAD: tight stenosis ostial LADLCx: tight stenosis ostial LCx, high OM1RCA: smooth, collaterals to LAD
CAG 1 Caudal.avi
CAG 3 Cranial.avi
CAG 4 RCA.avi

Via left femoral access (pre-existing IABP at right femoral), arrow sheath 7Fr was inserted in view of tortuous iliac artery. JL4 7Fr as guiding catheter, LCx (OM1) was wired with runthrough floppy & LAD was wired successfully with Fielder XT & Finecross microcatheter. LM, LAD & LCx were predilated sequentially with SC balloon 1.5mm & subsequently with NC balloon 3.0mm. LM-LAD was stented provisionally with Xience Alpine 3.5/23mm. Post dilatation & POT done with NC balloon 4.0mm. Later, decision was made to stent LCx in view of residual stenosis & possible plaque shift / thrombus at ostial LCx. LCx (OM1) rewired & jailed wire removed. LCx predilated with SC balloon 2.5mm. LM-LCx stented with Xience Alpine 3.0/15mm & postdilated at high pressure with stent balloon. LM-LCx was crushed then with NC balloon 4.0mm. LCx rewired & jailed wire removed. There was difficulty to pass balloon to LCx at level of ostial LM stent, despite on multiple maneuvers (rewiring, POT, balloon change, catheter adjustment). Catheter was changed to EBU 3.5 6Fr, then only able to finally pass SC balloon 1.5mm to LCx. Postdilate LCx stent with NC balloon 3.25mm. Kissing balloon technique with NC 4.5mm (LAD) & NC 3.25mm (LCx) and ended with POT with NC 4.5mm.
LAD 02 Final result after LAD stent.avi
LAD 05 Stent LCx (for reverse crush).avi
PCI 07 Final Result Spider.avi

This is a complex & high risk PCI, hence, IABP support is instrumental. The tight lesion were opened well with NC balloon, thus, eliminating the use of atherectomy. The aim is to keep thing simple & reduce ischemic time, so initially was planned for provisional LM-LAD stenting. However, in view of fear ofLCx occlusion, we decided to stent across LCx via reverse crush technique. Difficulty was encountered in passing down the balloon to LCx. Possibilities include non-coaxial catheter, wire entanglement & suboptimal stent expansion. The problem solved with EBU 3.5, which provided better support & coaxiality. The use of intracoronary imaging will provide us with added value.