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CASE20191113_013
| CORONARY - Adjunctive Procedures (thrombectomy, atherectomy, special balloons) | |
| Tunnel Drilling & Blasting | |
| Jonathan Gabriel Sung1 | |
| Tuen Mun Hospital, Hong Kong, China1, | |
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[Clinical Information]
- Patient initials or identifier number:
FWH
-Relevant clinical history and physical exam:
- Male, 70 years old- Smoker 10 cigs / day- History of diabetes mellitus, hyperlipidemia and obstructive sleep apnea- Complained of exertional chest pain 1-2 times per week- Physical examination unremarkable
-Relevant test results prior to catheterization:
CTCA: Proximal and mid LAD calcified 90% lesions; proximal LCx calcified plaque, distal LCx 80% lesion; RCA occluded
Echo: Dilated LA / LV, fair LV systolic function, EF 50% by Simpson, hypokinetic anterior region, normal RV systolic function, mild MR / AR, no PHT - Relevant catheterization findings:
LMS: normalLAD: ostial LAD 70% stenosis , tandem lesions at prox and mid LAD 90% stenosis, bifurcation lesion at mid LAD/D2 (Medina 1,1,1) with 70, 90 and 80% stenosisLCX: ostial LCx 30% stenosis, mid LCx 70% stenosis, distal LCx 80% stenosis, retrograde to dRCARCA: prox RCA 50% stenosis, mid RCA critical lesion and distal RCA total occlusion
 01) Left side coro.avi 04) Left side coro.avi 05) Left side coro.avi |
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[Interventional Management]
- Procedural step:
EBU3.5 7F engaged LMSion wired to dLADp-mLAD pre-dilated with Ikazuchi Zero 2.0/15 and NC Pantera Leo 2.5/8Unable to deliver Shockwave balloon 3.0/12 through mLAD calcified lesionShockwave therapy delivered along p-mLAD as it advanced through the calcified lesion (4-6 atm for 8 cycles)Further pre-dilatation with NC Pantera Leo 2.5/8Orsiro 2.5/35 deployed over m-dLAD and PSHP with Raiden-3 3.0/10
BMW Universal II wired to distal OM3mLCx-OM3 pre-dilated with Ikazuchi Zero 2.0/15 and NC Pantera Leo 2.5/8Orsiro 2.25/40 deployed over mLCx-OM3 at 8-14 atmPSHP with NC Oberon 3.0/20 over proximal stent edge and NC Pantera Leo 2.5/8 over mid-distal stent segmentPre-dilatation over pLCx with Raiden-3 3.0/10Raiden-3 3.5/15 placed in pLAD while Orsiro 3.5/26 deployed over o-mLCx at up to 14 atmRaiden-3 3.5/15 dilated over LM-pLAD at up to 20 atm to crush oLCx stent edgeBMW Universal II removed from LCx Orsiro 3.5/22 deployed over oLM-pLAD at 14 atm (overlapped with mLAD stent)PSHP over LM with Raiden-3 4.25/10 at 20 atm BMW Universal II re-wired into LCxIkazuchi Zero 1.5/15 delivered to LCx ostium, supported by anchoing NC Trek 3.5/12 at pLADLCx ostium re-opened with Ikazuchi Zero 1.5/15 and NC Sapphire II 3.5/10Further dilatation over LM-pLAD with NC Trek 3.5/12 at 20 atmKissing performed with NC Trek 3.5/12 over LM-pLAD and NC Sapphire II 3.5/10 over LM-pLCx at 6 atm simultaneouslyPOT over LM with Raiden-3 4.25/10 at 20 atmFinal angiogram showed satisfactory angiographic result 18) Deliver shockwave.avi 37) Post stent.avi 89) Final angio.avi- Case Summary:
- Shockwave balloon is a novel atherectomy technique which is safer than rotablation- Even if Shockwave balloon cannot be delivered to desired position due to tight calcium, it could deliver therapy to open up the way for it to advance further, like opening up a tunnel with drilling & blasting- Special precautions with Shockwave: risk of balloon rupture, difficult to re-insert used balloon (large profile), each balloon limited to 8 cycles of therapy
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