TB

TB was an 78 years old man with hypertension, dyslipidemia, and stage 3 chronic kidney disease. He had history of exertional angina for few months. Because of that, he went to hospital and his physician sent him to do an exercise-stress test. His EST was suggestive of myocardial ischemia. Then, he was scheduled for elective coronary angiography. His physical examination was unremarkable.

His resting electrocardiogram showed sinus bradycardia with rate of 55 bpm without significant ischemic change. During EST, his total exercise time was 5:30 minutes for standard BRUCE protocol and there was horizontal ST depression at lead II, III, aVF, V4, V5, and V6 at peak exercise.

Coronary angiogram via right radial artery access using 5-Fr. Tiger catheter showed: 
CAG 04.mp4
CAG 06.mp4
CAG 07.mp4

We engaged the LM artery using 6-Fr Guiding XB3.5 catheter. Sion Blue wire was at LAD and Runthrough guide was at LCx. IVUS at LM-LAD showed mixed calcium and fibrolipid plaque with severe stenosis from distal LM to mid LAD. We pre-dilated the lesion using 2.5-mm and 3.5-mm non-compliance (NC) balloons. Then, we put the Amphilimus-eluting stent size 3.50 x 46 mm to the LM-LAD. However, there was difficulty delivering the stent to the lesion because of heavy calcification and calcium nodule at distal LM. We used the GuidePlus extension catheter and switch guide wire from LCx to LAD for buddy-wire. After multiple attempts, we could finally position the stent and deployed at nominal pressure. Unfortunately, after stent deployment, the patient developed VT and VF. Angiogram showed completely jailed dominant LCx with TIMI-0 flow. CPR with defribillation and IABP insertion were performed immediately and we decided to initiate VA-ECMO. After completion of VA-ECMO cannulation and ROSC, we continued the PCI aiming to establish the flow at LCx. 4.0-mm NC balloon was used for POT of LM. Successful wiring of LCx was achieved by using Conquest Pro guide wire and Pilot200 guide wire with adjunct of Crusade dual-lumen microcatheter. Then, we changed to soft wire. 2.0-mm balloon was used to open the ostial LCx strut. Then, we stented the proximal LCx with 3.5 x 24 mm Everolimus-eluting stent. Then, we performed balloon kissing at LAD/LCx. POT of LM was done with 4.5-mm NC balloon.
PCI 15 Post stent (Jailed LCx).mp4
PCI 41 Final angiogram.mp4
PCI 45 ECMO and IABP.mp4

Learning points- Major side branch occlusion can be serious complication.- Bifurcation PCI using two-stent strategy should be considered in case of large/dominant side-branch.- Mechanical circulatory support is beneficial in high-risk PCI or in case of serious complication.