A.R.S.

We describe a 62-year-old male, non-smoker, with the cardiovascular risk factors of diabetes mellitus, hypertension, and chronic kidney disease first presented to a non-PCI capable district hospital for NSTEMI. He was treated with optimal medical therapy and subsequently referred to us, the PCI-capable hub hospital. Mr ARS was then reviewed in the clinic, he was in NYHA II and CCS I symptoms. Physical examination was unremarkable; however, he was troubled by poorly controlled diabetes mellitus. 

Creatinine 149 umol/L, estimated GFR 41.3 mL/min/1.73 m²Total cholesterol 4.2 mmol/L, LDL Cholesterol 1.8 mmol/L; HDL Cholesterol 1.5 mmol/L; Triglyceride 2.0 mmol/LFasting blood sugar 12.5 mmol/LElectrocardiogram: Incomplete left bundle branch blockEchocardiogram: Poor left ventricular ejection fraction of 30 - 35%, dilated left atrium and left ventricle, global hypokinesia, global longitudinal strain -11.8%, mild mitral and tricuspid regurgitation. 

CAG showed proximal LAD 70% stenosis, mid LAD chronic total occlusion with collateral from RCA; mid LCx 30% stenosis; distal RCA 70% with PDA 90% stenosis. The syntax I score 26.5, Syntax II for PCI 44.3, CABG 34.6; J-CTO score 1.Cardiac MRI showed LVEF 50%, MI at LAD and RCA affecting less than 3 segments. All segments are viable. In view of multivessel disease and poorly controlled Diabetes, we discussed with the patient regarding CABG vs multivessel PCI and the patient opted for the latter. 
Pre PCI RCA.mp4
Pre PCI LCA.mp4

PCI to dRCA – PLVEngaged with JR4, wired to PLV with RUNTHROUGH wire. Predilated with SC 2.0 x 12 balloon from dRCA to PLV. Residual stenosis <30% with no flow-limiting dissection. Subsequently treated with Paclitaxel Drug-Coated Balloon (DCB) 2.25 x 20 at nominal pressure for 60 seconds. Post PCI, it showed 10% residual stenosis, TIMI III flow with no dissection. 
PCI to pLAD – mLAD CTO:The case started with engagement of LCA with XB 3.0 6F, and RCA with JR 4.0 6F for contralateral injection to properly assess the retrograde collateral. In view of the favourable proximal CTO cap, we decided to start with an antegrade approach. 
Mid-LAD CTO managed to cross with fielder XT-R together with FINECROSS microcatheter. True lumen was confirmed with contralateral injection. The mid LAD seems small vessel with diffuse disease. We planning to approach the case with hybrid DES spot-stenting and DCB to the mid-CTO diffuse small vessel segment if possible. We predilated midLAD CTO with a 2.0 x 12 NC balloon. Then prepared proximal LAD lesion with 2.0 x 12 NC, followed by 2.25 x 20 previous DCB SC balloon. We then stented pLAD with a 2.75 x 16 everolimus DES and post-dilated with NC 3.0 x 10 up to 18atm. This followed by treating the mid LAD CTO with Sirolimus DCB 2.0 x 30 at nominal pressure for 110 seconds. The residual stenosis was around 10%, TIMI III flow with no dissection seen. Total contrast was 200ml, with a screening time of 20.5minutes and a total procedure time of 78minutes.
PCI to RCA.mp4
PCI to LAD.mp4

Drug coated balloon is gaining popularity in multiple indications, including in-stent-restenosis, small vessels disease, bifurcation lesion, and even chronic total occlusion in our cases. We are convinced that hybrid therapy with spot stenting using DES together with DCB will be the feasible, attractive and practical strategy for treating patients with de-novo complex lesions.