55 year old man with underlying severe plaque psoriasis on s/c ustekinumab had an anterior myocardial infarction in 2012 while travelling. He was not offered thromblysis and had only underwent angiogram 2 weeks later after returning and LAD was stented.  In 2023, he had NSTEMI and during that time, his ejection fraction had worsen to 30% and cardiac MRI showed non viable LAD. Repeated angiogram showed ISR 99% of LAD, recessive LCX and CTO dominant RCA. 

Cardiac MRI : Ischemic dilated cardiomyopathy with moderate LV systolic dysfunction ( LVEF 32% ) and normal RV systolic dysfunction ( RVEF 58% ). Minimal viability seen within mid to apical anterior, mid to apical anterior-septum and all apical segments ( Non viable mid LAD territory ) . All other segments are viable

His angiogram showed proximal LAD stent ISR 99%, mid LAD stent ISR 95%, LCX smooth and large dominant mid RCA chronic total occlusion with bridging collaterals. The J-CTO was 4 and the 1st attempt to intervene the CTO RCA by another operator failed.  Using IVUS and also branches of RCA, we determined our stent and DEB size and length. From the IVUS also noted pseudo lesion or concertina effect caused by the tortuous vessels.

SAL used as guide for RCA and JL diagnostic for contralateral injections. Failed to cross with Fielder XTR in Finecross but successfully cross with Gaia 1st with an anchor balloon support due to tortousity. Unable to pass down Finecross thus lesion was prepared and wire was exchanged successfully. IVUS  was able to only advance till mRCA and noted diffuse disease from mid to proximal RCA. Further lesion prepared with 2.0 and 3.0 balloon. Able to send IVUS down further and noted attenuated plaque and vessel size of 4.5mm. In view of tortuosity, Guidezilla used to send a 3.5x38 stent. While advancing Guidezilla, there was pressure damping and patient developed chest pain and VF requiring cardioversion. Atropine and nitrates were given and stent was immediately deployed. With Guidezilla, stent post dilate with a 4.0 balloon. Noted filling defect at proximal stent and suspected thrombus. ACT remained more than 300 at all times. IC tirofiban was given and IVUS confirmed thrombus. Aspirations done showed red thrombus and IC streptokinase given. Decided to stop for proper anticoagulation. Relook coros after a week showed resolution of thrombus. pRCA, mRCA and dRCA prepared with a 3.5 scoring and 2 3.5x30 DCBs were deployed using Guidezilla with balloon assisted technique.  Another 3.5x25 DCB overlapped with distal stent segment. Wire removed and noted slow flow. Noted dissection at the distal RCA. Immediately rewire and stent with a 3.5x22 stent and post dilate with a 3.5x10 balloon.

Patient well and his EF had improved from 30% to 40% and now symptoms free. During the procedure, we wondered why patient had thrombosis despite ACTs were adequate. We found out that s/c ustekinumib, the biologics used for his psoriasis had been reported to have increased incidence of thrombosis. Other learning points in this case are tortuous vessel is the bane of intervention, even more so in CTOi. Next in tortuous vessels, wires, IVUS and Guidezilla can cause pseudo lesion, also known as concertina effect. DCB can be a good option in tortuous vessels if proper preparations is done and always be prepared with managing flow limiting dissection.