CORONARY - Bifurcation/Left Main Diseases and Intervention
Urgent PCI in a Complex Left Main Bifurcation for an ESRD Patient with Recurrent ACS
Kim Fong Ng1, Chuey Yan Lee1, Mahadevan Gurudevan1, Heng Shee Kim2, Kumutha Gobal1, Adelyn Nisha Henry1, Vicknesan Kulasingham1, Tee Choon Keong1, Azrina Abdul Kadir1, Hou Tee Lu1
Hospital Sultanah Aminah, Malaysia1, Sultanah Aminah Hospital, Malaysia2,
A 70-year-old male, non-smoker with background history of diabetes mellitus, hypertension, benign prostate hypertrophy, and end stage renal disease on regular haemodialysis presented with multiple admissions of unstable angina and NSTEMI.Patient developed hypotension due to poor tolerability with haemodialysis. Therefore, he was switched to peritoneal dialysis.His Blood pressure was 106/60 mmHg and pulse rate was 62/min.Respiratory examination revealed bibasal crepitation.
Blood investigations showed Hb of 12.1g/dl, creatinine 603 μmol/L, troponin T 2265.Echocardiography examination revealed reduced left ventricular function with ejection fraction of 40%, dilated left atrial, global hypokinetic and there was no clot or thrombus observed.There was also no pericardial effusion observed.ECG showed LVH pattern and T wave inversion V2 to V6.
Chest X-ray showed cardiomegaly. 3.mov 2.mov 4.mov
The right femoral artery (RFA) was punctured. IABP was on standby mode.
A 7Fr JL 4 was used to engage LMT. A BMW II J tip wire was inserted into LCx and another wire runthrough floppy wired down to LAD. The LCx was predilated by NC 2.5x12mm balloon.
Long LCx lesions was treated with Sirolimus-coated balloons (SCB)
(2.5x30mm, 2.5x20mm, 2.75x20mm).
LAD was predilated using a 3.0x15mm NC balloon.
The mid LAD lesion was treated with drug-eluting stents (DES, 2.75x38mm).
LMT and proximal LAD were treated with DES (4.0x32mm).
IVUS was performed.
Post-dilated LMT with 4.5x8mm NC balloon and LAD with 4.0x15mm NC balloon.
Sequential balloon dilatation at proximal LAD with 4.0x15mm NC balloon and proximal LCx with 3.0x12mm NC balloon. Final kissing balloon of proximal LAD and LCx.
Final POT at LMT with 4.5x8mm NC balloon. IVUS was performed again.
Good result. Patient underwent heamodialysis well and his functional status improved
remarkably after revascularization.
PCI is an alternative treatment strategy for high surgical risk patients, especially with ESRD & recurrent NSTEMI
For significant ostial Lcx involvement, 2 stents strategy is recommended, however, in patient with ESRD, the In-stent restenosis rate is very high.
Several studies reported that, compared with 2-stent techniques, the provisional 1-stent strategy for LM bifurcation was associated with better outcomes, lower risks of major adverse cardiac events, death & MI. The stenting strategy is an important prognostic factor when deciding the optimal revascularization treatment.
Imaging such as IVUS is vital as the vessel size can be underestimated using angiographic interpretation.