TCTAP & AP VALVES 2020 Virtual

CASE20191115_012

CORONARY - Complications
A Difficult Retrieval of Emboshield® Device in Graft Percutaneous Transluminal Coronary Angioplasty
Siddhartha Mani¹, Abhishek Roy, Koushik Dasgupta¹
NH-Rabindranath Tagore International Institute of Cardiac Sciences, India¹,

[Clinical Information] - Patient initials or identifier number: Mr. PPK / 96782/2019 -Relevant clinical history and physical exam: A 75 years old, hypertensive, diabetic gentleman was admitted with complaints of exertional angina for the last one year, increasing in intensity over the last one month. He had a history of undergoing CABG, post an episode of unstable angina, in 1998 for severe triple vessel coronary artery disease and was already on optimal medical therapy. His pulse was regular, 70/min, blood pressure was 104/64 mm Hg, cardiovascular and respiratory system examinations were unremarkable. -Relevant test results prior to catheterization: He had a haemoglobin of 15.5 gm%, eGFR of 69 ml/min, increased triglyceride levels and an HbA1c of 7.1%.His electrocardiogram showed LVH, bifascicular block with 1^st degree AV block, T wave inversion in anterolateral leads.His echocardiogram showed dilated left ventricle, generalized wall hypokinesia with an ejection fraction of 35%. - Relevant catheterization findings: Coronary angiogram revealed a native triple vessel coronary artery disease with LMCA involvement.LMCA - tubular 70% stenosisNative LAD and LCx were totally occluded.RCA – Prox tubular 99%LIMA to LAD graft was patent.RSVG to OM graft showed 80% proximal stenosis followed by a mid 80% stenosis. This was also retrogradely supplying the PDA and PLV branches of the RCA.Intervention in the RSVG to OM graft was planned with the provision of an embolic protection device. A01. PKP LCA.avi A02. PKP RCA.avi A03. PKP RSVG TO OM GRAFT.avi
[Interventional Management] - Procedural step: Femoral arterial access was obtained. A JR 3.5 guiding catheter was engaged into the ostium of the RSVG to OM graft and an Emboshield device with wire and filtration device was introduced. After wire crossing, the filtration element was negotiated distal to the two lesions. Serial predilatations with a 3.5 mm NC Traveler balloon were done. A Biomime 4.0 X 37 mm stent was delivered smoothly at the distal lesion. A second Biomime 4.0 X 40 mm stent was deployed in the proximal lesion, just overlapping the first stent, with some difficulty.At this point, slow flow was observed in the RSVG graft which was probably due to the distal device. Post-dilatation was done into both the stents with a 4.0 mm NC Traveler balloon, but slow flow still persisted.The retrieval catheter was then taken but could not be negotiated distally. Unpredictably, in the pull-push effort to manipulate the catheter, the filtration element got dislodged proximally up to the distal end of the first stent. A second Runthrough Intermediate wire was then taken up to the filtration element and an attempt to deliver the retrieval catheter was made. After careful and simultaneous manipulation of the retrieval catheter, guide catheter and the second wire, finally, after quite some time, success was obtained. The filtration element was then withdrawn. Final angiographic images showed a good result with restoration of TIMI 3 flow in the graft. B01. PKP PROXIMAL DISLODGEMENT OF FILTRATION ELEMENT IN PULL-PUSH.avi B02. PKP ADVANCEMENT OF RETRIEVAL CATHETER OVER 2ND WIRE.avi B03. PKP FINAL RESULT.avi - Case Summary: Graft PTCA should ideally be done under distal embolic protection. Retrieval of the filtration element usually is reasonably straightforward. However, sometimes it may be difficult to negotiate the retrieval catheter and may lead to displacement of filtration element. So, one needs to be resourceful and cautious. Proper guide catheter selection and support is also essential. Taking the help of a second coronary wire might be of some benefit occasionally.

E-Science Station