A 67 YEAR OLD MALAY GENTLEMAN, EX SMOKER WITH UNDERLYING HYPERTENSION, DYSLIPIDEMIA AND PSORIASIS WAS SEEN IN OUR CARDIOLOGY CLINIC FOR CHRONIC STABLE ANGINA. HOWEVER FOR THE PAST 4 MONTHS HE HAS BEEN HAVING RECURRENT ANGINA AND WAS ADMITTED MULTIPLE TIMES FOR UNSTABLE ANGINA.

REPEATED ECG IN WARD SHOWED SINUS RHYTHM WITH NO ISCHEMIC CHANGES.ECHOCARDIOGRAPHY SHOWED GOOD LV FUNCTION WITH EF 60%, NO REGIONAL WALL MOTION AKINESIA. VALVES AND CHAMBERS ARE NORMAL.IN VIEW OF RECURRENT ADMISSIONS FOR CHEST PAIN, HE WAS THEN SCHEDULED FOR CORONARY ANGIOGRAM.

CORONARY ANGIOGRAM REVEALED CHRONIC TOTAL OCCLUSION AT THE MID LEFT ANTERIOR DESCENDING ARTERY (MLAD) WITH COLLATERALS FROM RIGHT CORONARY ARTERY. OTHER CORONARIES ARE NORMAL.



cto lad.mov
dual shot rao cranial.mov

WE DECIDED TO INTERVENE THE CTO MLAD IN VIEW PERSISTENT ANGINA. BILATERAL RADIAL ARTERY PUNCTURE, WITH ANTEGRADE APPROACH. WE ENGAGED RIGHT CORONARY ARTERY WITH JR4 6 FR AND WIRED DOWN WITH RUNTHROUGH FLOPPY. ENGAGED THE LEFT CORONARY ARTERY WITH EBU 3.5 7FR. INITIALLY TRIED TO WIRE THE LAD WITH FINECROSS MICROCATHER (MC) USING SION BLACK WIRE BUT FAILED. SUBSEQUENTLY CHANGED TO GAIA 1^ST AND MANAGED TO CROSS SUCCESSFULLY. IVUS SHOWED 360 DEGREE CALCIFICATION WITH 270 DEGREE CALCIFICATION MORE THAN 5 MM, IVUS CALCIUM SCORE 2. CALCIUM DEBULKING WAS DONE USING ROTABLATION WITH 1.5 BURR RUN 3 TIMES AT 220 KRPM FOR 10 SECS AND POLISHING RUN TWICE AT 140 KRPM. POST ROTA SHOWED PRESENCE OF FRACTURED CALCIUM WITH REVEBERATION SIGN. LESIONS WAS PREPARED FURTHER USING WOLVERINE 3.0 X 10MM AND 3.5 X 10MM. POST CUTTING BALLOON SHOT SHOWED NO DISSECTION, TIMI 3 FLOW AND RESIDUAL STENOSIS 30%. DECIDED FOR DCB WITH PANTERA LUX 3.0 X 20MM AND AGENT 3.50 X 30MM. FINAL SHOT SHOWED TIMI3 FLOW, NO DISSECTION SEEN. PATIENT REMAIN ASYMPTOMATIC AT 6 MONTHS  AND REPEATED COROS SHOWED MODERATE STENOSIS AT MLAD WITH NEGATIVE FFR (0.92).




post 2nd dcb.mov
post 6months.mov

THE MAIN AIM TO INTERVENE THE CTO IS MAINLY TO IMPROVE SYMPTOMS.J CTO SCORE WAS 1 AND IVUS CALCIUM SCORE WAS 2. PROPER ARTHERECTOMY WAS DONE WITH ROTABLATION AND CUTTING BALLOON. POST LESION PREPARATION SHOWED NO DISSECTION,TIMI 3 FLOW AND RESIDUAL STENOSIS <  30%. HE HAS CALCIFIED LESION WHICH PREDISPOSE TO ISR OR STENT THROMBOSIS IN FUTURE.HENCE DCB WAS CHOSEN.SIX MONTHS POST INTERVENTION SHOWED MODERATE STENOSIS AT MLAD WITH NEGATIVE FFR VALUE (0.92) AND PATIENT REMAIN ASYMPTOMATIC. ROLE OF DCB IS NOT WELL ESTABLISHED IN CTO AND CALCIFIED LESION. THIS CASE SHOWED THE OUTCOME OF DCB IN CTO CALCIFIED LESION AFTER PROPER VESSEL PREPARATION.