LLS

LLS is a 56-year old man, with background of type 2 diabetes mellitus, hypertension, chronic kidney disease stage 2 (eGFR 71ml/min/1.73 m2) and previous anterolateral myocardial infarction in 2017 which was successfully thrombolysed.

He has severe left ventricular dysfunction with ECHO showed LVEF 30-35% with global hypokinesia and mild mitral regurgitation. His Creatinine was 129 umol/L (eGFR 71 ml/min/1.73 m2).

Coronary angiogram on 10^th October 2018showed triple vessel disease with calcified and diffuse 80-90% stenosis from proximal to distal LAD, 80% stenosis in the proximal LCX and 90% stenosis indistal RCA and PLV. He was referred for CABG surgery, however, it was deemed unsuitable by surgeons due to poor target vessels. Therefore, PCI to distal RCAand proximal LCX was done earlier on 4^th February 2020 and staged PCIto LAD later.
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He was electively admitted for staged PCI to LAD on 25^th August 2020. Procedure was done via right femoral artery access. Intracoronary Heparin 6,000 U and Clopidogrel 300 mg were given. 6 French EBU 3.5 guiding catheter was engaged to the left system. Runthrough NS over microcatheter Corsair was wired down to distal LAD. Mid LAD was predilated with SC Emerge 1.2 X 12 mm. Then runthrough NS was changed to Rota wire and proximal to mid LAD was rotablated with 1.5 burr at 180 RPM for 4 runs. Further predilated mid LAD with Emerge 2.0 x 12 mm. Mid LAD was stented with PromusPremiere 2.25 x 32 mm and proximal LAD with Promus Premiere 2.75 X 20 mm. Post-dilated proximal LAD stent with NC Emerge 3.0 x 12 mm. We then predilated distal LAD with SC Emerge 2.0 X 20 mm and drug coated balloon (DCB), IN.PACT FALCON 2.0 X20 mm deployed. We then wired distal LCX with runthrough NS and predilated mid LCX with SC Emerge 2.0 x 12 mm. DCB IN.PACT FALCON 2.25 X 14 mm was deployed to mid LCX successfully. Finally, we proceeded with PCI to PLV with engaging 6 French JR4 to the right coronary ostium. Runthrough NS through microcatheter Corsair to PLV. Predilated PLV with SC Emerge 2.0 X 12 mm and DCB IN.PACT FALCON 2.25 X 20 mm deployed to PLV. End result was fairly good with TIMI 3 flow. Total contrast used was 300 ml. Patient was discharged well 2 days later.
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Complete revascularization in triple vessel disease and high risk patient is feasible with staged multivessel PCI without any complication. However, it requires careful planning which involves staged procedures, use of rotablation in calcified LAD and adequate hydration.