Madam LCY

Madam LCY is a 70 years old lady who has underlying hypertension, diabetes mellitus and end-stage renal disease on regular haemodialysis. She presented with frequent episodes of chest pain during haemodialysis and intradialytic hypotension for 1 month.Her blood pressure was 170/70 mmHg, pulse rate 97 beats per minute, oxygen saturation 97 % under room air.Physical examination was normal. 

ECG showed sinus rhythm and Q wave at lead III. Echocardiography showed a left ventricular ejection fraction of 55 % and hypokinesia at inferolateral, inferoseptal and inferior wall. 

Coronary angiography showed 70 % stenosis at mid-left anterior descending (LAD) artery, 70 % stenosis at mid-left circumflex (LCX) artery and a chronic total occlusion (CTO) at proximal right coronary artery (RCA) with retrograde flow from LAD.  The calculated SYNTAX I score was 18.0 and SYNTAX II score was 49.7.Patient was discussed regarding options of coronary artery bypass surgery versus multi-vessel percutaneous coronary intervention (PCI). She refused surgery and opted for PCI.
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Bilateral femoral artery puncture was done with 6Fr femoral sheath. Coronary guide catheter 6Fr XB 3.5 was used for left coronary artery and 6F AL 1.0 was used for RCA. Coronary physiology was done to LAD and LCX prior to coronary intervention. Intracoronary adenosine 200mcg bolus was used for hyperaemia.  Fractional flow reserve (FFR) value of LAD was positive with 0.76 and FFR value of LCX was negative with 0.9. FFR of RCA was not done as it was a CTO at proximal RCA. The CTO RCA was crossed antegradely by Fielder XT wire with Finecross mirocatheter. After confirmed that it was a true RCA lumen by retrograde contrast injection, the Fielder XT wire was exchanged with Runthrough Floppy workhorse wire. The Finecross microcatheter was removed by trapping balloon technique. The proximal RCA was predilated with Wilma SC 2.0 mm balloon and Goodman NC 3.0 mm balloon.  Subsequently, 1 drug eluting stent Orsiro 3.5 mm was implanted at the proximal to mid RCA. The stent was postdilated with Accuforce NC 3.5 mm balloon. TIMI 3 flow of RCA was achieved.Post PCI to RCA, coronary physiology was performed again with intracoronary adenosine. FFR value of RCA was 0.98 and the FFR value for LAD and LCX had improved to 0.85 and 0.93. As the FFR value for both LAD and LCX were negative, coronary intervention to LAD and LCX was not indicated.  
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From visual angiography assessment, this patient has triple vessel disease with a CTO at RCA which received collateral flow from a diseased LAD. Pre-PCI FFR assessment showed negative ischaemia at LCX and positive ischaemia at LAD. After revascularization of CTO RCA, the LAD's FFR has changed from positive to negative. This is because the LAD perfusion territory was reduced as it no longer needed to provide collateral flow to RCA. The use of FFR has reduced the number of stents required in this patient and has changed a CABG strategy to a single vessel PCI. This case highlights the importance of coronary physiology guided PCI which will provide a better outcome for the patient.