R K

A   73 year old female , MRS  R K, presented to Emergency Room  with history of  acute complaints of breathlessness and chest pain of two hours duration .  ECG showing acute ST elevation Inferior Myocardial infarction. She had past history of NIDDM since 6 years with no history of hypertension or ischemic heart disease in past. Clinical examination revealed Heart rate 96/min, BP 120/70 . Oxygen Saturation  was 98% on room air

ECG –showed  Inferior myocardial infarctionwith ST elevation in 2,3, AVFShe was given loading dose of 150 mg aspirin, 180 mg Ticagrelor and 80 mg atorvastatin and shifted to Cath lab for urgent primary angioplasty  

Angiographywas done from right femoral route and right venous  sheath was also placed.Left Main –normalLAD -  showed proximal highly calcified 90 %followed mild aneurysmal dilatation and another 80 % proximal stenosisLCX  - is non dominant and  normalRCA –dominant,  with highly calcified proximal 95% followed by long calcific 90% lesion in mid RCA and two high grade lesions of 90% distally 

Urgent primary angioplasty of  RCA was taken up and LAD was planned as staged PCI. The right coronary artery was cannulated using 6F JR 4 guiding catheter . the RCA lesions were crossed with  Turn Trak wire , however due to heavy calcification, balloon could not be tracked beyond mid RCA . Hence predilatation of proximal lesion was done using 2.5 X 15mm N C trek balloon. This was followed by slows flow ,transient bradycardia and sustained ventricular tachycardia. Urgent D C cardioversion was done and pacing lead placed in RV . A 3.0 X 28 Xience Alpine Stent was urgently placed in osteoproximal RCA to keep the vessel open. Using guideliner support a balloon could then be advanced and the distal lesions were  dilated. However the mid RCA lesion could not be dilated due to heavy calcification. Hence a Wolverine 2.75 X 12 balloon was used which could successfully dilate the lesion. Then using grand slam buddy wire for support, 2.75 X 33 Xience Alpine Stent was deployed in distal RCA overlapped by another 3.0 X 38 Xience Alpine Stent from mid to proximal RCA upto the proximal stent with good result.Staged PCI of LAD was done after 3 weeks. The lesion was predilated with 2.5 X 15 mm balloon followed by 2.75 X 12 Wolverine cutting balloon. A 2.75 X 28 Xience Alpine Stent was deployed in mid LAD overlapped by 3 X 28 mm Xience Alpine Stent in proximal LAD. The proximal  aneurysmal area of the stented segment was post dilated using 3.5 X 12 mm balloon with good result. 

This case demonstrates that in patients with  acute myocardial infarction and highly complex calcified lesions, there is need for use of  available technologies like cutting balloon and guide liner to achieve a satisfactory result. In  an emergency situation of urgent primary angioplasty , the culprit infarct related vessel has to be revascularized ,however complex the  lesions are. In this  case of acute myocardial infarction  with highly calcified complex RCA having multiple lesions, successful PTCA was done for RCA using guideliner, cutting balloon and multiple stents, and the patient made a complete uneventful recovery. Staged PTCA of calcified LAD was performed , also using a cutting balloon.