Ms A

72-year-old Ladyu/l Ischemic heart disease - prior NSTEMI in September 2021      Hypertension       Dyslipidemia Done angiogram previously in another hospital but no intervention, suggested for CABG but patient refused Referred to us for further management On clinical examination patient fully conscious NYHA class 1, CCS 2-3 Lungs clear breath sound No pedal edema Blood pressure 128/70 mmHg PR 72 bpm

Blood investigations:Urea 4.4 mmol/LCreatinine 57 mmol/LNa 143 mmol/LK 3.9 mmol/LWcc 7.29 x 10*3 / uLHb 12.9 g/dLPlt 203 x 10*3 g/uL
ECG: Sinus rhythm with Wellen type 2 changes on chest leads ECHO: Dilated LA 4.3cm, diastolic dysfunction grade II           Thickened AMVL with Moderate MR, No MS, No AR/AS seen            Mild TR with PSAP 26+3mmHg            NO LV thrombus, no pericardial effusion            Hypokinetic mid to apical, septal and anteroseptal wall           LVEF 51% Biplane Simpson 

Coros diagnostic findings :Calcified distal LMS 30-40% stenosis LAD: Calcified proximal to mid 80-90%, distal 60% stenosis LCX: Calcified, minimal disease RCA: Dominant, ostium and mid RCA 60-70% stenosis 


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We engaged left coronary system with EBU 3.5 and wired down with Sion Blue in Teleport Microcatheter into LAD. Sion Blue exchanged with Fiedler XTR but failed to cross. Crusade microcatheter into Fielder XTR with 2^nd wire Sion Black  for support but failed. Wires removed and Sion Blue wired into LCX for extra support. Sion Black in Crusade introduced into Sion blue and attempt to cross LAD but failed. Sion Black upgraded to Fielder XTR but all attempts to cross LAD was unsuccessful. Next, attempted to wire into LAD with Gaia 1^st with the aid of IVUS guidance but unsuccessful. Then, decided to change guide catheter to JL 3.5. With much difficulty, we wired down LAD successfully with Runthrough Floppy. Finecross into Runthrough Floppy and exchange to Rota-wire. Finecross removed via balloon trap and RotaLink 1.5 mm inserted and bur commenced. Rotawire exchange to SIon Blue via FineCross into LAD. Run through floppy into LCX to improve guide support. Mid LAD lesion cut with Wolverine 3.0x10 mm and at this point noted patient was hypotensive with ST elevation over inferior limb leads on cardiac monitoring likely due to dissections and plaque distal embolization. Started inotrope infusion and immediate stent deployed with Promus Premier 2.25x24 mm. Noted blood pressure improved and inotropes requirement reduced. Next proximal LAD cut with Wolverine 3.0x10 mm. After IVUS decided to stent LMA. Stent LMA with Resolute Onyx 3.5x26 mm and POTS with NC Euphora 4.5x8 mm. After IVUS run proximal LAD stent with Resolute Onyx 3.0x22 mm. Noted slow flow phenomenon of LAD, aspiration catheter (Thrombuster) into LAD and vasodilators given with Adenosine, Verapamil and Isoket. Flow improved. Wires out and final angiographic showed good TIMI 3 flow obtained. Inotrope off at the end of the procedure. 
LAD + LMS diadnostic .mp4
Rotablator into LAD .mp4
Final angiogram.mp4

At the end of procedure, inotrope was weaned off and patient was asymptomatic of hypotension and angina. Patient was discharged the next day. In conclusion, with diligent planning and proper strateg,y full re-vascularization is achievable in a complex lesion. Proper choice of guiding catheter is important and extra coronary wires for support will be of help as in this case. IVUS-guided puncture for crossing the stenosis is also an option and is very useful to assess the degree of stenosis and intimal diameter to choose correct stent size. Proper vessel preparation is important as well as management of intraprocedural complications such cardiogenic shock and slow flow phenomenon.