BGS 22/0371940

We present a case of an 80 y of age man with coronary risk factors diabetes, hypertension, dyslipidemia and familiarity without previous history of cardiac disease and known nephrolithiasis and urethral stenosis. He came to our observation during the second COVID wave pandemic within the emergency department for chest discomfort during hypertensive crisis and evidence of not known complete left bundle branch block and minimal elevation of TnI-HS levels.

Echocardiography demonstrated septal dyskinesia with ejection fraction of 53%, no relevant valvular disease. The patient was hospitalized with the diagnosis NSTEMI for early coronary angiography within 24 hours and therapy according to the ESC 2020 NSTEMI Guidelines was initiated: acetylsalicylic acid 100 mg SID (no P2Y₁₂ receptor inhibitors in unknown coronary anatomy), low molecular weight heparin atorvastatin 80 mg, ace-inhibitor, beta-blocker, rapid insulin and adequate hydration.

Angiography shoed critical mid RCA and ostial, LM (Medina 1.1.1) mid LAD and LCx stenosis (Fig.1). The patients definitively refused surgical revascularization choosing percutaneous one. At this point the mid (Fig.2.a.) and ostial RCA (Fig.2.b.) stenosis were fixed with DES with optimal angiographic and IVUS (Fig.2.c-d.) results. The left coronary system was studied with IVUS demonstrating significant LM/LAD/LCx stenosis and presence of circumferential calcification (Fig.3.a-b). 

As a first step we performed rotational atherectomy on the axis LM-LAD (Fig. 3.c.) and LM-LCx (Fig. 3.d.) with 1,75 mm burr and after rewiring LAD (Renato) and LCx (Sion Blu) we repeated IVUS evaluation. Predilatation with non-compliant balloons of mid LAD and LCx and LM-LAD and LM-LCx (Fig.4.) was performed and then a bifurcation dedicated stent BIOSS was places on the axis LM-LCx (Fig. 5.a-b). The procedure continued with placing of a second DES in the mid LCx (Fig.5.c-d) and third DES in the mid LAD (Fig.6.a-b.). Then we placed a fourth DES (Fig.6.c-d.) in the axis LM-LAD (culottes with the just placed BIOSS on LM-LCx). Procedure was ended with DOT, POT, kissing balloon and final POT. Optimal result with IVUS (Fig.7.a-d) and angiography (Fig.7.e-f.) was achieved. The patient was discharged after 48 hours on DAPT and clinical follow-up was scheduled for 1^st and 3^th month and angiography control after 6 months.

Adopting the common rules and guidelines in the every day practice as in our case with NSTEMI patient rule-in/rule-out, early coronary angiography in less than 24 hours from admission, all vessels revascularization during index hospitalization, imaging in the left main treatment, stent like preparation of vessels before stenting and in some cases using of dedicated bifurcation stent can increase the success rate and reduce the complication rate.