E-Science Station

SBS

A 53-year-old male, smoker, with underlying hypertension admitted to a private hospital for acute coronary syndrome, and subsequently the patient was referred to our center for CABG because of failed percutaneous coronary intervention (PCI). On arrival, he had NYHA I, CCS I – II symptom. 

ECG: sinus rhythm with Q wave inferior leadHemoglobin: 139 g/LCreatinine: 91 umol/l; eGFR: 83 ml/min/1.73 m²Fasting blood sugar: 4.9 mmol/LTotal Cholesterol: 3.7 mmol/L; LDL Cholesterol: 1.8 mmol/L; HDL Cholesterol 1.4 mmol/L; Triglyceride: 1.2 mmol/LEchocardiogram: preserved left ventricular function with LVEF 50-55%, normal chambers and valves.

CAG at previous centerLM 50%pLAD 95%mLAD 60%pLCx and dLCx 50%pRCA 50%, CTO mRCAdistal RCA stent implanted into false lumen causing no re-flow from mRCA onwardsSYNTAX I score is 36.
Repeated CAG in our center: similar finding with total occluded mRCAReferred for CABG, patient declined. 
We performed an IVUS guided PCI to:pLAD and mLAD with Resolute Integrity 3.0x34pLCX with Impact Falcon 3.0x20ostial LM to ostial LAD with Resolute Integrity 4.0x12
Planned for staged PCI to CTO mRCA in 1 month.

J-CTO score 3. PCI strategy: antegrade wire escalation (AWE), if fail, for retrograde wire escalation (RWE). Bi-femoral approach. LCA engaged with XB3.0 7F, RCA engaged with AL 0.75 6F.  The case started with antegrade wiring to RCA with Fielder XT-R with Mogul microcatheter support. However, the XTR entered false lumen.Attempted retrogradely, wired into the epicardial collateral channel with Sion wire and Caravel microcatheter. Unfortunately, unsuccessful. Re-attempted antegrade wiring, eventually able to wire into distal RCA true lumen with Fielder XTR and Mogulmicrocatheter. True lumen confirmed with contralateral collateral injection and later with IVUS. Distal RCA was pre-dilated with Ikazuchi zero 1.0 mm x 6 mm balloon, followed by Pantera Pro 1.5 mm x 10 mm balloon and Emerge 2.0 mm x 8 mm balloon. Distal RCA stented with Promus Premier2.25 mm x 16 mm DES and post dilated with Emerge NC 3.5 mm x 15 mm balloon.
Repeated IVUS showed good apposition of the distal RCA stent and under-expansion of previous proximal RCA stent. Proximal RCA stent was post-dilated with Emerge NC 4.0 mm x 15 mm balloon.
Post PCI IVUS showed no distal stent edge dissection with good apposition of the stent. 

This case illustrated the danger of implanting a stent into false lumen. When the distal wire position is ambiguous in a CTO, the operator should refrain from implanting a stent without confirming that the wire is truly intraluminal either by IVUS , contralateral injection etc. However, false lumen stenting is salvageable by careful planning and applying the correct strategy in our case.