E-Science Station

MR RI

65 years old with underlying diabetes mellitus, atrial fibrillation and triple vessel disease. He had an ejection fraction of 26% with viable myocardium based on technetium scan. Patient strongly refused bypass surgery. In view of him being symptomatic of chest pain, he was counselled and agreed for high risk Percutaneous Coronary Intervention. Physical examination revealed no significant findings. 

Blood parameters within normal range.
echo 1.mpg
echo 2.mpg

Coronary angiogram findings Left main stem – Body – distal left main stem moderate to severe stenosis LAD – Proximal – mid-severe disease and calcified. LCX - diffuse disease from ostium to mid vessel, CTO mid vessel with retrograde from OM branch RCA – Severe diffuse disease, calcified.
cine 1.mpg
cine 2.mpg
cine 3.mpg

IABP inserted via left femoral artery and 7Fr sheath to the right femoral artery. JL 4.0/7frguide catheter was used. Run-through floppy wired into the LAD and Fielder XT into the LCX. 1.0mm balloon was unable to pass into the mid LAD. Guide catheter was switched to an EBU 3.5/7Fr for better support.1.0mm balloon was unable to cross the lesion. Directional atherectomy was done using a 1.25 burr for 3runs. The mid to proximal LAD was then sequentially predilated using a1.0/10mm, 1.5/10mm, 2.0/15mm, and a 2.5mm balloon. DES 2.75/32mm was unable to pass the mid LAD. Sequential pre-dilatation was done to mid LAD using an NC3.0/15mm and NC 3.5/15mm. The DES 2.75/32mm was then able to be deployed at themid-proximal LAD. Stent balloon was pullback and went up high pressure. There was poor flow down the LCX. Patient subsequently developed hypotension requiring inotropic support with Noradrenaline and Dopamine. Ostial of LCX was predilated with a 2.5/15mm balloon. The ostial- proximal LCX was stented using a DES 3.0/15mm and stent crushed with an NC 3.0/15mm balloon.  LCX was rewired and post dilation with an NC3.0/15mm. The Left Main – LAD was stented with a DES 2.75/29mm.Mid to proximal LAD was post dilated with an NC 3.0/15mm and LM-LAD was post dilated with an NC3.5/15mm. 
POST CINE 1.mpg
POST CINE 2.mpg
post cine 3.mpg

This was a case that showcased a complex left main bifurcation stenting with directional atherectomy. We also successfully dealt with Slow flow down the LCX vessel which initially resulted in hypotension.