Patient K.G. ID 408

Female 71 y.o.Clinical symptoms: stable angina (CCS III, NYHA II). Previous myocardial infarction (2017). Previous PCI of RCA (2018).Comorbidities: Hypertension, dyslipidemia, family history.20/05/2022 patient underwent coronary angio – 3 vessel disease (RCA; LAD; LCX)Recommendation for CABG, strongly denied by the patient.03/11/2021 patient was referred to the Fedorovich Klinikasi LLC for PCI.

LM bifurcation stenosis - 30-50% (Medina 1:1:1). LAD - severe calcification and significant stenosis - 90% of middle part. LCX - severe calcification and significant stenosis - 80% of distal part. RCA - significant ostial stenosis. In middle part significant stenosis - 85%. PDA - middle part stenosis - 80%. Before implanted stents are without in-stent restenosis. 

What’s next?1.   Balloon occlusion!!!2.   The next important thing is to calm down and gather your thoughts!!!3.   Don’t hesitate to call for help!4.   Check the available covered stents and tools (microcatheter, guide extensions etc.)! Next step is distal embolization -     We putted more distally our extension guiding catheter to reduce the flow.-     We guided the dual-lumen microcatheter as distally as possible (due to the lack of conventional microcatheters – corsair, fine cross etc.).-     We used 2 neurovascular coils – «Axium PRIME 1.5mm/2cm» (just 2 coils was available).-     One coil was detached more distal to avoid any retrograde flow and continue of bleeding and the second before perforation.-     It was not enough for embolization and bleeding continued.-     Due to my lack of experience with distal embolization using fat, I thought that the soft part of the tip of guide wire would be the best option. But as this is the first time situation in my life I cut it - 3cm, then I realized it was useless, so the second time I cut off only 1.5cm and bent it a few times, at list it worked. 

1) Never underestimate “simple” lesions2) Always control the distal tip of your GW even its looped (safe)3) Calm down and gather your thoughts4) Don’t hesitate to call for help!5) In case of fail you always can put a crossover covered stent to close branch artery (last chance – live saving)6) Be always flexible to change the strategy for optimizing patients long term outcome