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Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-024

The Road Less Travelled

By Kogulakrishnan Kaniappan, Balachandran Kandasamy, Beni Isman Rusani, Afrah Yousif Haroon, David Yong

Presenter

Kogulakrishnan Kaniappan

Authors

Kogulakrishnan Kaniappan1, Balachandran Kandasamy2, Beni Isman Rusani1, Afrah Yousif Haroon1, David Yong1

Affiliation

National Heart Institute, Malaysia1, Subang Jaya Medical Centre, Malaysia2,
View Study Report
TCTAP C-024
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)

The Road Less Travelled

Kogulakrishnan Kaniappan1, Balachandran Kandasamy2, Beni Isman Rusani1, Afrah Yousif Haroon1, David Yong1

National Heart Institute, Malaysia1, Subang Jaya Medical Centre, Malaysia2,

Clinical Information

Patient initials or Identifier Number

BGM

Relevant Clinical History and Physical Exam

62 years old lady , with recent admission for Unstable Angina, presented with chest pain for 1 week.Premorbid :1.   Coronary Artery Disease           -history of PCI to LM / LAD / RCA in 2016               *[ LM stent 4.0 x 8mm , overlapping LAD stent 3.0 x 38mm ]            -history of PCI to ISR LAD in August 20202.  Diabetes Mellitus , HbA1c 9.23.  Hypertension4. Dyslipidemia, LDL 1.8
Onexamination :Alert, not tachypnoeicTemp : 37cBP : 150/90 mmHgHR : 90 bpmCVS : DRNMLungs : ClearNo pedal edema

Relevant Test Results Prior to Catheterization

BloodInvestigation :FBC        : Hb 12.6 / WCC 6.4 / PLT 240RP          : Urea 3.2 / Na 139 / K+ 4.0 / Creat 60Trop T   :  negativeFSL         :  TC 2.9 / TG 2.3 / LDL 1.8Hba1c    :  9.2Electrocardiogram (ECG) :SR, normal axis, Q wave in lead III, ,no ST changesChest X-ray :Cardiomegaly , clear lung fieldExercise Stress Test :Positive at stage 2 , ST depression in lateral leadsEchocardiography : LVEF 55%, anterior wall hypokinesia, , normal diastolic function , TAPSE 1.7cm, no LV thrombus

Relevant Catheterization Findings

LMS : mild ISR Left Main Stem stentLAD : severe In-stent restenosis of proximal LAD stentLCX : tight ostial LCX diseaseRCA : mild ISR RCA stentPCI to LAD:EBU 3.0,6Fr engaged LM.RunThroughFloppy wire crossed the lesionIVUS pre PCI:  LMS stent: calcified plaque seen in 1arc , mild ISR. Proximal LAD stent: calcified plaques seen in 2 arc with calcium nodule @3o’clock ; stent under-expandedPredilated ISR LAD with NC Balloon but failed to expand well despite few attempts. Case abandoned
Left coronary sytem angiogram.avi
Righ coronary system angiogram.avi
NC Trek 3.0x12mm failed to expand fully.avi

Interventional Management

Procedural Step

Staged PCI to LM/LAD +/- LCXRight femoral approach, 7F sheath.EBU 3.5,7Fr guiding catheter.Runthrough Floppy wired into LAD. SION Blue wired into LCX. Optical Coherence Tomography (OCT) catheter cannot cross the LCX lesion. OCT of LAD : 2 quadrant of heavy calcium seen with neoatherosclerosis ; under-expanded stent.Distal vessel size 3.0mm ; proximal LAD size.3.5mm.Predilate LCX with NC 2.0x12mm. Intravascular Lithotripsy (IVL) Shockwave Balloon 2.5x 12mm placed at calcified plaque area inLAD stent.Balloon inflation done successfully for 5 cycles of 10 pulses each; balloon well expanded.The same IVL Shockwave Balloon now re-introduced into LCX ostioproximal segment.Balloon inflation repeated in Left Circumflex for another 3 cycles of10 pulses each, balloon well expanded. OCT now able to pass the LCX lesion. Noted cracked calcium with fibrofatty plaques.Predilated LAD stent with NC 3x15mm. Predilated proximal LAD-LM stent with NC 3.5x15mm. Predilated LCX again with NC 2.75x23mm.Stented LCX : XIENCE SIERRA 2.75x23mm.Post dilated LCX with NC 2.75x15mm.Reverse crushed LCX stent with NC 3.5x15mm placed in LM. Flip-flop both wires done.Kissing balloon inflation using NC 3.5x15mm in LAD and NC 2.75x15mm in LCX. Drug coated balloon (DCB) 3.0x15mm deployed at proximal LAD stent at 6 atm for 1minute. DCB 3.5x25mm deployed at LM-LAD stent at 6tm for 20seconds x 2.POT done at distal LM with NC4.0x8mm. Final OCT showed no stent edge dissections, well opposed stent with cracked calciums.
IVL shockwave balloon used in LAD.avi
Same IVL shockwave balloon used to predilate LCX.avi
Final results after final POT balloon.avi

Case Summary

 Conclusion
  1. Novel usage of Intravascular Lithotripsy in Severe In-stent Restenosis (ISR) with the background of coronary artery calcification (CAC), especially in calcified nodule is a viable and safe option, compared to other atherectomy devices.
  2. Deployment of same IVL balloon catheter in 2 different vessels is feasible and effective, as demonstrated in our novel case using this approach.
  3. Further prospective trials and clinical evidences required to review and expand the indication of IVL in such selected cases.

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