Madam HZ

A 59 years old lady was referred from dialysis center for intradialytic chest pain and hypotension. She was treated for diabetes mellitus, hypertension and end staged renal disease on regular haemodialysis via right fistula. She presented with chest pain during dialysis for the past 2weeks associated with hypotension and difficulty in breathing. Her blood pressure was 180/90mmhg, heart rate 66bpm and saturation 99% . Lungs auscultation found basal crepitation , no murmur heard. 

Her laboratory shown urea 14 mmol/l , creatinine 644 umol/, haemoglobin 19g/dl, Troponin I 127ng/l which was raised.  Her electrocardiogram shown sinus rhythm , T wave inversion at lateral lead . She was treated for non-ST elevation myocardial infarction. Coronary angiography was performed on the next day of admission.

In view of the presence of  fistula at right arm and high aPTT post haemodialysis with heparin , left distal radial artery was punctured at left snuffbox and 6Fr sheath was inserted.  Coronary angiography done with JR 3.5 and JL 4.0 revealed co-dominant vessels, distal left main 20-30% stenosis, proximal LAD severe stenosis with heavily calcified vessel, distal LAD 50% stenosis. Normal LCx , and moderate lesion at RCA. Decision was made for angioplasty over the LM-LAD with rotational atherectomy. 

Guiding catheter EBU 3.5 6Fr was used to engage left coronary artery with good support, wired into LAD. Pre IVUS assessment revealed the minimal lumen area was 2.48mm² at proximal LAD, 180 – 360 degree of superficial calcium from mid to proximal LAD, LAD size was 4mm and LM size was 6-7mm ( Fig. A, B, C). Rotablation  to mid and proximal LAD with burr 1.75mm 5 runs at 180,000 rpm. Subsequently predilated LAD with NC balloon 3.0mm and scoring balloon 3.5mm.Stented mid to proximal LAD with DES  3.5 x 38mm and LM-LAD with 3.5x28mm (Synergy  Megatron, Boston Scientific ). Post dilatation of LAD and LM with NC balloon 4.0. IVUS assessment post dilatation shown well opposed and good minimal stent area ( 13mm²  ) for LAD stent, however LM size was 7.0mm ,stent was undersize ( Fig. D )  , further upsize the LM stent with NC balloon 5.5x8mm and 6.0x8mm high pressure ( 20atm ). Good final PCI result . Patient was able to tolerate haemodialysis without chest pain , she was discharged well and medical therapy to RCA . 

In our case, vascular access was a challenge for the patient . Distal left radial was used as she has right fistula and femoral puncture was avoided due to high aPTT post haemodialysis with heparin. The guiding catheter stability and support was good despite using the distal left radial access , able to perform rotablation with 1.75mm burr without difficulty. Another challenge in this case was size discrepancy in LAD and LM , an appropriate stent selection is important in order to upsize to desired stent size . Imaging in PCI is important especially for optimal stent sizing and enhanced lesion preparation e.g. atherectomy in our case.