E-Science Station

LSL

65-year-old gentleman, presenting with acute onset of left sided chest pain associated with sweating, dizziness. Diabetes, hypertension as underlying medical issues and also history of inferior myocardial infarct in 2007. On examination, vital signs were stable apart from bibasal crepitation over both lungs. Treated as non ST elevation myocardial infarction. Started on dual antiplatelets, subcutaneous LMWH, sugar optimization and close  monitoring of vital signs were done.

Raised cardiac enzymes with normal renal and liver function were noted. ECG showed ST segment depression over I, AvL, V5, and V6. On arrival cardiac enzymes –CKMB 2.9, Trop I 0.07 Serial cardiac enzymes noted as follows: CKMB 2.9 à 37.7 à 66.6 Trop I 0.07 à 1.87 à 10.1Serial ECG and cardiac enzymes were done with close monitoring of vital signs. CXR showed normal cardiac size.

Failed medical therapy with ongoing chest pain and dynamic ECG changes over lateral leads warranting the need for urgent percutaneous coronary intervention.Puncture from right radial artery using 6 French sheath.Patent stent in right coronary artery, significant lesion in ostial and proximal left circumflex artery, mild plaque disease in left anterior descending artery were identified in diagnostic angiogram.
Right coronary artery .wmv
left coronary system .wmv

First Runthrough wire in left circumflex and second Runthrough wire in left anterior descending artery were placed. Balloon dilatation was done by using 2.5 x 15 mm to proximal and ostial left circumflex artery. No dissection noted on post balloon dilatation. Proceed with drug eluting stenting 3.0 x 40 mm to ostial left circumflex artery. Proximal end of the stent protruding into the distal left main stem was noticed after deploying the stent. Optimization of stent with non-compliant balloon 3.0 x 15 mm.Plaque shift to ostial left anterior descending artery noted after balloon dilatation. Prepare the ostial left anterior descending artery with balloon dilatation 3.5 x 15 mm.Proceeded with drug eluting stent 3.5 x 20 mm to ostial left main stem to proximal left anterior descending artery. Managed to exchange wire but failed to cross with the balloon for kissing balloon. IVUS was done to identify the stent strut optimization. Well-apposed stent was noted. While removing the IVUS, noted the guide wire was moving along.Attempting to wire down to the left anterior descending artery as the tip of the wire was stuck in the distal end of the stent.
With minimal force applied, the wire was pulled along the stent and the stent became deformed. Rewire with Fielder XT to left anterior descending and left circumflex artery. Balloon dilatation was done to distal left main and ostial left anterior descending artery with 1.0 x 15 mm, upsize to 2.0 x 15 mm, 3.0x 15 mm and up to 3.75 x 15 mm.
LAD PCI .wmv
Complication accordion and fracture stent.wmv

Positioning of the stent in the ostial coronary artery is challenging and need to optimize from different angle of fluoroscopy.Plaque shift to the left anterior descending artery is also common complication of ostial left circumflex artery stenting.Challenging in exchange wires in bail out bifurcation stenting. IVUS plays an important role in identifying the possibilities of malapposed stent strut. Need to be careful on removing IVUS as the wire may get along. Fracture wire with deformed stent will happen when the wire is stuck in the stent strut.