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CORONARY - Chronic Total Occlusion
Antegrade Percutaneous Coronary Intervention to Left Anterior Descending and Left Circumflex Artery Using Controlled Dissection and Different Tools
Kogulakrishnan Kaniappan1, Afrah Yousif Adam Haroon1
National Heart Institute, Malaysia1,
[Clinical Information]
- Patient initials or identifier number:
-Relevant clinical history and physical exam:
Mr SS is a 49 year oldgentle man with background history of :1. Ischemic Heart Disease - triple vessel disease based on coronary angiogram done early 20192. Dyslipidemia 3. Chronic Obstructive Airway Disease He presented with worsening dyspnea and chest pain for the past 6 months. He refused coronary artery bypass graft surgery and presented to us to explore the option of percutaneous coronary intervention. Clinically, he was not in respiratory distress and hemodynamically stable
-Relevant test results prior to catheterization:
Full blood count :Hemoglobin 14.1 g/dL , White blood cell 7.8 x 109/L , platelet 337 x109/LRenal profile : urea 3.8 mmol/L, sodium 142 mmol/l, potassium 4.6mmol/l, creatinine 95 umol/lLiver function test : albumin 46 g/l , bilirubin 6 umol/l,  alanineaminotransferase 86 u/lTroponin-T high sensitive - 16 pg/ml
Transthoracic echocardiographyEjection fraction 50% , septal and inferior wall hypokinesia. Valves normal. No Left ventricular thrombus. Nopericardial effusion
- Relevant catheterization findings:
Coronary Angiography Findings :
Left Main stem - normalLeft Anterior Descending Artery - total occlusion at proximal segment Left Circumflex Artery - moderate to severe lesion at ostial of Obtuse Marginal 1 ( OM1 )Right Coronary Artery - Mid segment severe stenosis
Impression : Triple vessel disease
[Interventional Management]
- Procedural step:
Right radial and right femoral access secured. EBU 3.5/7F for Right system and AL 1.0/7F for Left system. PCI to CTO LCx attempted. Hi-Torque PILOT 200 wire with Corsair microcatheter used to cross the lesion and wired down to OM1. RUN THROUGH FLOPPY wired down the LCx. OM1 predilated with TREK 2.5mm x 12 mm and  then stented with Synergy 2.5mm x 38 mm. POT placed at proximal OM with NC Emerge 4.0mm x 8mm . Post dilated distal OM1 with NC Emerge 3.0 x 20mm. Good final results with TIMI 3 flow. Next, PCI to CTO LAD attempted. RUN THROUGH FLOPPY in CORSAIR micro catheter used to wire down the D1. Conquest PRO 12 wired down LAD. Unable to cross and keep entering the sub intimal space. Changed to Miracle 3 wire and attempted to cross,however failed. Strategy now to use CROSSBOSS CTO catheter with PILOT 200 wire to cross the lesion by creating a well controlled dissection. Then, exchanged PILOT 200 with STINGRAY balloon and wired down the sub intimal space and position adjusted with contralateral shot.The STINGRAY wire used to puncture the true lumen and wire removed. Exchanged STINGRAY with CONQUEST PRO wire to cross the LAD lesion. RUN THROUGH FLOPPY wired down the LAD. Lesion predilated with TREK 3.5 x 15 mm. IVUS used to measure vessel size and sub intimal segment. SYNERGY 4.0 x 48 mm stent deployed upto ostial LAD. Post dilated with NC TREK 4.0 x 20mm. Another stent SYNERGY 3.0 x 12mm deployed at distal LAD, upsized at overlap site.Good flow achieved, no immediate complication.
3. OM1 stented with Synergy 2.5x38mm at 12 ATM.avi
14. Final shot - good flow over LAD post stent dilatation.avi
- Case Summary:
IVUS demonstrated well opposed LAD stent and only a short segment of sub intimal space stent with no evidence of dissection. Good flow in LAD achieved with no immediate complications .Total contrast used for both PCI to CTO LCx and CTO LAD was only 300mls of Ultravist 350 and total radiation reduced to 1725 mGy. We wish to highlight that the usage of different coronary wires and tools early in the CTO intervention with strategy to create controlled dissection successfully help to shorten the procedural time, minimize contrast usage and effectively reduce radiation exposure.
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