Mr S is a 56 year old man who is a chronic smoker.He has known DM & hypertension.He presented with exertional shortness of breath for 6 months. ECG showed sinus rhythm with poor R wave progression.CXR clear. A1c 9.5 LDL 2.5 The blood count, liver and kidney function tests; and cardiac markers are not remarkable. 

Echo Dilated LV and LA. RV and RA size normal. Severely impaired LV systolic function with LVEF 33%Hypokinesia over basal inferior, mid and apical region. Akinesia over mid and apical inferior region.Impaired RV systolic function.Moderate functional MR, mild to moderate TR, mild AR Thin rim of pericardial effusion
He was started with anti heart failure medications.coro/PCI was arranged.

Coro 8/2023LAD: diffused severe stenosis upto 80% from pLADLCX: CTO after OM1 bifurcation, critical stenosis over pOM1RCA: pRCA ~70% stenosis, CTO after mRCA, retrograde supply from LADConclusion: Severe TVDPatient opted for multivessel PCI over CABGPCI done to p-dRCA w/ DES x 3 first

Stage PCI was arranged 2 months later.LMS engaged with EBU PCI done to p-dLAD with DES x3 first Initially plan medical treatment over LCxbut LCx successfully wired with to OM2 with Fielder XT-R under Caravel supportLCx dilated with 1.0 and 1.5 balloon IVUS showed diffuse disease til pLCX Further dilated with 2.0 balloon Wire to NS runthroughDecided for DEB and see response2.0, 2.5 & 3.0 DEB was used Angiogram showed dissection at pLCx, decided for stentingOM1 was wired with sion for protection 2.0 & 3.0 stent were deployed Angiogram showed TIMI II flow at OM1OM1 was rewired and dilated with 10 balloon stents dilated with 2.0, 2.5 and 3.0 balloonsIVUS guided stent optimization with 2.0 and 3.0 balloons again final angiogram showed satisfactory results.

This case highlights a challenging scenario with CTO. Despite successful wiring of CTO, it is difficult to decide the next suitable action. We attempted to avoid stenting in this case with DEB due to small vessel and no good landing, but eventually stenting has to be done due to dissection which further complicated the PCI with the impinged flow of the side branch. So there is no hard rule to tell whether DEB or stenting is superior, and the decision is to done on a case by case basis.