ID of KCGMH: 60483297 ; Mr. Dai

. This 76 y/o male with HCVD and hyperlipidemia presented to a cardiologist with UAP.. (+) Thallium.
. Preserved LV function (EF = 65%) s/p elective Dx cath. Via RFA. Neither renal insufficiency nor coagulopathy was revealed.. The patient remained in the throes of crescendo angina after two sessions of PCI carried out at two separate hospitals.. He was referred to our hospital for the 3rd session of PCI.

none

. LAD CTO, critical lesions in RCA and LCx were detected.
. Pinhole balloon rupture was already observed during the previous session. 

. Given the failure to perform antegrade wiring of the LAD artery during the first and second sessions, retrograde wiring was intended from PDA to LAD through septal branches. . During the 3^rd session of PCI, hematomas were noted in two of the aforementioned branches.. With the PL branch involved, balloon anchoring technique was employed to enhance the support of the guiding catheter. . A hematoma was observed again at the anterior branch. . On account of massive pericardial effusion and hemodynamic instability, emergency pericardiocentesis was carried out.

. Residual hematomas were still noted.. The coronary angiography showed the absence of distal RCA in the 3^rd session.. On account of significant vascular calcification, no retrograde wiring was feasible.. PCI to d-RCA and p-RCA rather than LAD was carried out as a result.. Eventually, intramural hematomas and dissection involving PDA were detected. . The LAD CTO remained an unsolved problem.. Whether PCI should be carried out for the 4^th time remains undecided.