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CORONARY - Complex and Higher Risk Procedures for Indicated Patients (CHIP)
Complex PCI In An End-stage Renal Failure Patient
Ka Chun Un1, Anthony Yiu Tung Wong1, Cheung Chi Simon Lam1, Chor Cheung Tam1
Queen Mary Hospital, Hong Kong, China1,
[Clinical Information]
- Patient initials or identifier number:
-Relevant clinical history and physical exam:
Mr Lee,M/72, has history of diabetes on insulin. He had diabetic nephropathy ondialysis. He also had history of peripheral vascular disease and lung shadowunder investigation. He presentedto the medical team for chest pain and shortness of breath. Physical examinationshowed ankle edema and lung crepitations. He was diagnosed to suffer from acutecoronary syndrome and ischaemic acute pulmonary edema. 
-Relevant test results prior to catheterization:
Electrocardiogramshowed dynamic T wave inversion over anterolateral leads.Echocardiogramshowed globally impaired left ventricular ejection fracture of ~30%, more markedover anteroseptal and apical regions. Myocardial perfusionscan showed hibernating myocardium over mid-distal anteroseptal, apical, inferiorand inferolateral segments. Post-stress left ventricular ejection fraction was~16%. 
- Relevant catheterization findings:
Coronary angiogram:Left maincoronary artery: ostial 40-50% diseaseLeftanterior descending artery (LAD): calcified lesion, proximal to mid 90% disease,distal 80%Left circumflexartery (LCx): small, minor diseaseRight coronaryartery (RCA): proximal 80%, mid 99% critical lesion, distal 90% 
[Interventional Management]
- Procedural step:
Patient wasdeclined from surgery so complex percutaneous coronary intervention (PCI) isplanned.Intra-aorticballoon pump (IABP) was inserted in view of left main with triple vesseldisease and poor left ventricular function.PCI to RCAwas first attempted. 6Fr JR4 was used as guiding catheter. Posterolateralbranch was wired. Lesion was dilated with 2.25 balloon. Intravascularultrasound (IVUS) was performed for assessment. Drug eluting stents (DES) of3.0/15 mm, 3.0/28 mm and 3.5/28 mm were deployed. Stents were furtherpost-dilated. PCI toLM-LAD was performed with 7Fr Jr4 guiding catheter. IVUS showed calcifiedplaque at LM to ostium with severe luminal stenosis. Rotablation was performedwith 1.25 Burr at 180,000 rotation per minute for 8 passes. Lesion waspre-dilated with scoring balloon 2.25 mm and 2.75 mm. DES 2.5/29 mm and LM-LADwith DES 3.5/29 mm were deployed. Further proximal optimization(POT) and post-dilatation were performed. IABP wasremoved and exchanged to a 8Fr sheath. Femoral angiogram showed high puncturesite, high bifurcation with underlying disease. 8Fr Angioseal (Terumo, Japan)was applied to reduce risk of retroperitoneal bleeding. Contralateral femoralangiogram showed occluded left femoral aryery. Bail out common femoral arteryangioplasty was performed. The occlusion was crossed with a 0.035guidewire. Wire was exchanged with a 0.018 wire. Stenosis was dilated with4.0 and 6.0 mm balloon. Final angiogram showed re-established flow.
- Case Summary:
This case demonstrated a complex PCI for a high risk patient. Atherectomy is often required in severely calcified diseases especially in renal failure patient. Besides, Extra caution has to be taken for femoral puncture to avoid puncturing on diseased portion. Concomitant peripheral vascular disease would increase the risk of applying sealing device. As a result, clinicians has to be prepared for bail out peripheral angioplasty in case complication arises. 
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