Mr. L is a 63-year-old patient admitted to our hospital in October 2020 for Left Main pattern STEMI with VT/VF arrest. He is a chronic smoker, and his CT coronary angiogram done in September 2020 showed TVD with a significant calcium score with multiple calcified plaques along coronary arteries.
He was found collapse on floor after arguing with colleagues.
AED attached by colleague showed suspected VT but no shock given.
While ambulance arrived, he had undetectable BP, but pulse present.
No VT noted. No CPR all along. No shock given.
GCS remained 3/15 since 1st medical assessment.
He was intubated in AED.
PCI was started with LAD.JL 3.5 Hyperion 7F was used to engage LM.
Fielder XT-R was used to wire to dLAD, then exchanged to Runthrough NS with Caravel.
Guideline Plus was used for guiding extension support.
There was difficulty in passing through balloon or IVUS through the mLAD lesion.
Abbott Dragonfly Opstar was used for lesion assessment at LAD. It showed a calcified nodule at mLAD.
It was decided to proceed to stenting to dLAD first and LCX before dealing with mLAD in the end.Sequentially LAD was dilated with Ryurei 1.5/15, Sapphire 1.5/15, Ikazichi 1.0/6, Raiden 1.5/8 & Raiden 2.0/10Coroflex 2.0/16 was deployed at mLAD at 16 atm.
Orsiro 2.5/30 was deployed at pLAD at 22 atm.
PSHP with Pantera Leo 2.5/15 at 20-24 atm.
Angiogram showed dissection at mLAD.
Coroflex 2.5/19 was deployed at m-dLAD at 10 atm.
PSHP to mLAD with Ryurei 2.5/10 at 16 atm. PSHP to pLAD with Raiden 3.0/15 at 20 atm.
After that, LCx was stented.
Sion was used to wire to dLCx, which was predilated with Raiden 2.0/10 at 12 atm.
Orsiro 2.5/30 was deployed at p-dLCx at 12 atm.
Orsiro 3.0/13 was deployed at pLCx (overlapping) at 12 atm.
PSHP to mLCx with NC Pantera Leo 2.5/15 at 22 atm.
PSHP to pLCx with NC Sapphire 2.75/15 at 20-24 atm.
Finally, it came to ostial LAD stenting.
Abbott Dragonfly Opstar was used for lesion assessment at LAD. It showed a calcified nodule at mLAD causing malapposition of stent and dissection flap.
mLAD lesion was again dilated with Shockwave 3.0/12 at 6 atm for 4 times then Accuforce 3.0/15 at 18-22 atm.
Coroflex 3.5/12 was deployed at ostial-pLAD at 14 atm.
OCT showed good apposition of stent, good expansion.
The final angiogram showed satisfactory angiographical results, TIMI III flow. Very mild dissection at mLAD (covered with stent already) shot2.avi shot3.avi
The patient had successful PTCA/S to ostial-dLAD with 4DES (shockwave assisted), p-dLCx with 2 DES. He was planned for stage PCI to RCACTO. He was eventually extubated and discharged home.
This case illustrated a scenario in which there is difficulty in balloon dilatation in mLAD stenosis. Subsequently, it was found with the use of OCT the culprit was a calcium nodule around the mLAD, which was quite different from intraluminal plaques we encountered usually. The LCX and dLAD were stented beforehand for stabilization before dealing with the difficult part in mLAD. Shockwave balloon was used to pass through the lesion. Finally, the mLAD was successfully stented with good angiographical result. In the case of complex PCI, good planning is important to success. Imaging modalities, such as IVUS or OCT can help us in identifying the nature of lesion and planning so as to decide the strategy for the procedure.