DB

A 37-year-old gentleman with no comorbidities presented with progressively worsening effort angina and dyspnea on exertion since past 4 month. He had a history of anterior wall ST elevation myocardial infarction (STEMI) with delayed presentation 4 months back and was on medical therapy for the same. At presentation physical examination including cardiovascular examination was unremarkable.

An electrocardiogram revealed qRBBB pattern. Echocardiogram showed anteroseptal hypokinesia with a reduced ejection fraction of 44%.Cardiac biomarker - Troponin I kit test was negative at presentation. Rest of the laboratory parameters were within normal limit.

A coronary angiogram revealed bifurcating normal left main coronary artery, chronic total occlusion (CTO) of left anterior descending (LAD) after first diagonal (D1), nondominant left circumflex (LCX) diffuse distal disease and two obtuse marginals (OM) having 50-60% lesion, and dominant right coronary artery (RCA) having CTO of posterior left ventricular branch. Based on these findings after a heart team and informed patient discussion LAD intervention was planned. 

The patient was taken to cardiac catheterization laboratory and through a 6 French (Fr) right radial access the left ostium was engaged with a 6 Fr XB guide. The LAD lesion was crossed with a Fielder XT A guidewire, however, even a 0.85 * 10 mm nic nano balloon could not be crossed across the lesion. The same was tried with a different Fielder FC wire but to no avail. The procedure was abandoned at that point and a reattempt was planned with high speed rotational atherectomy (HSRA). For the second attempt a 7 Fr femoral access with a 7 Fr JL guide was taken, the lesion was crossed with a Fielder FC guidewire. Angiographic shoot on this instance revealed better visualization of distal vessel because of a greater number of microchannels due to the previous attempt, but still even on this instance a 0.85 mm balloon could not be crossed. The wire was then exchanged for a rota wire using microcatheter. Rotational atherectomy was then performed with a 1.5 mm burr at 1,80,000 rpm. The lesion was then again dilated with a 2.5 * 12 mm non-compliant (NC) balloon and stented with a 2.75 * 26 mm drug eluting stent (DES) and post dilated with a 2.75 * 10 mm NC. D1 lesion was crossed with Fielder FC wire, pre dilated with 2 * 10 mm semi compliant balloon, stented with 2.5 * 26 mm DES and post dilated with a 2.5 * 12 mm NC. Final angiographic shoot revealed good stent optimization. The patient was discharged after 24 hours of the procedure without any periprocedural complications. 

Angioplasty in a balloon uncrossable lesion poses a unique challenge to the operator. A pragmatic approach to dealing with such lesions at first include increasing guide catheter support (7 Fr or 8 Fr), use of additional guidewire support, using microcatheters, or using low profile (0.85 – 1.5 mm) SC balloon with lubricious coating. Failing these strategies more advanced techniques like atherectomy – laser, HSRA, or orbital can be employed, as demonstrated in this case.