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TCTAP C-086

Chain Reaction--Endless Nightmares!

By Dhiman Banik

Presenter

Dhiman Banik

Authors

Dhiman Banik1

Affiliation

National Heart Foundation Hospital & Research Institute, Bangladesh1,
View Study Report
TCTAP C-086
Coronary - Complex PCI - In-Stent Restenosis

Chain Reaction--Endless Nightmares!

Dhiman Banik1

National Heart Foundation Hospital & Research Institute, Bangladesh1,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

•    Mr. X-29 years old, Physician by profession.
•    Hypertensive, Strong family history of IHD.
•    H/O PCI (LAD).
•    H/O CABG (LIMA to LAD, Sequential SVG to D1 and OM branch).
•    Now presented with chest pain & SOB for two days.
•    NSTEMI.

Relevant Test Results Prior to Catheterization

•    CBC:Hb:11.9 gm/dl
•    RBS: 5.9 mmol/L,
•    S. Creatinine 1.3 mg/dl
•    ECG shows T¡é in V1-V6.
•    Echo reveals no regional  wall motion abnormality with LVEF -60%.

Relevant Catheterization Findings

First CAG: Left Dominant & PCI was done in LAD.
After 6 months of PCI, patient developed NSTEMI.
Again Check CAG done: severe ISR in LMCA with significant stenosis in LCX ostia.
CABG  done, but after 14 months patient again developed NSTEMI.
Check CAG revealed:
LMCA (significant ISR)   & LAD (100% ISR).
Dominant LCX with 90% ostial stenosis.
SVG to OM & D1 showed Severe stenosis in its proximal  part as well as distal anastomotic site.
LIMA to LAD stenosis distal anastomotic site.



Interventional Management

Procedural Step

•    LCX was wired with floppy wire.
•    Pre-dilatation was done with 3.5 x 09 mm NC balloon at 20 ATM.
•    Subsequent Pre-dilatation was done in LM with 4.0 x 09 mm NC balloon at 18 ATM.
•    LAD was wired with CTO wire.
•    Pre-dilatation in ISR.
•    4.5mm x 22 mm DES was inflated in LMCA to LCX
•    IVUS study LMCA to LAD was done.
•    Final kissing was done with 3.5 x 25 mm DEB in LAD & 4.5 x 08 mm in LMCA to LCX.
•    Distal LAD dilated at low pressure with 2.0 X 15 mm balloon.
•    IVUS was done revealed good expansion & well apposition.




Case Summary

•    Any PCI or CABG is not free from life threatening complications.
•    Before doing an ostial LMCA in a left dominant case the pros and cons should be carefully assessed.
•    Proper sizing & placement of the stent is mandatory.
•    Stent should be properly inflated & over hanging in the aorta  should be avoided.
•    For the proper assessment of lesion severity in ostial Left main, IVUS & FFR can be of immense value.
•    In fact overhanging of the stent lead to great difficulty during check CAG & redo PCI.