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CASE20191101_011
| CORONARY - Chronic Total Occlusion | |
| Revascularization in Patient with TVD with Mid LAD and Proximal RCA CTO via Antegrade and Retrograde Approach | |
| Muhammad Idu Jion1, Jack Wei Chieh Tan1 | |
| National Heart Centre Singapore, Singapore1, | |
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[Clinical Information]
- Patient initials or identifier number:
CBH
-Relevant clinical history and physical exam:
52-year-old man, co-morbidities diabetes, dyslipidemia, smoking Hx .Presented with decompensated heart failure Nov 18.Patient developed worsening leg swelling and breathlessness on exertion for 6 months.Physical examination showed presence by lower limb edema and lung crepitation.Improved with heart failure medications.
-Relevant test results prior to catheterization:
Hb 16 g/dLCreatinine 84 umol/LHBA1C 7.4%TC 5.5 HDL 1.7 LDL 3.2 mmol/L
2DE (17/11/18) Severely impaired LV function, LVEF 18%. - Relevant catheterization findings:
Cath (16/11/18) TVD with pLAD 80%, D190%, mLAD CTO, mLCX 80%, OM1 80%, pRCA CTO. Collaterals from OM to dRCA and to LAD.Planned for CABG but LV clot noted on MRI 15/11/8, 11/2/19 and 29/4/19, despite adequate warfarinisation.Referred back for PCI option.
 1RAOCAU.wmv 2laocra.wmv 3RCALAO.wmv |
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[Interventional Management]
- Procedural step:
Complete Revascularization was done over three stages.1) For the first PCI (7/6/19), Antegrade attempt to cross mLAD CTO was unsuccessful. pLAD-D1 lesion was stented with DESYNEX2 2.5 x 32mm and XIENCE ALPINE 2.25 x 28mm stents.LCX lesions were also treated. pLCX-OM was also stented with RESOLUTE ONYX 2.5 x 26mm and p-mLCX lesion was stented with DESYNEX2 2.5 x 23mm stents, utilising the culotte technique.
2) The second PCI (21/08/19) focused to treating the RCA. RCA was crossed antegradely and stented from proximal-distal RCA with ONYX 4.5x 22mm, BIOMIME 3.5 x 48mm, ULTIMASTER 4 x 9mm and RESOLUTE ONYX 3.5 x 34mm stents. 3) The third stage (2/10/19) involves a retrograde PCI attempt to the LAD through the previously stented RCA segments. RCA was wired with CORSAIR and RUNTRHROUGH wire. Retrograde septal channel was wired with SUOH 3 wire. CORSAIR was exchanged for CARAVEL which managed to negotiate the retrograde channel. CTO was eventually crossed with ULTIMATE BROS3 wire and externalised with RG3 wire.p-mLAD was predilated with 2.0 balloon and stented with XIENCE XPEDITION 3.0 x 48mm and BIOMATRIX 2.5 x 33mm stents. Kissing balloon dilation was done to LAD-D1 bifurcation. finalRight.wmv confirmationinjection.wmv finalRAOCRA.wmv- Case Summary:
Complex multivessel PCI is an option for patients with multivessel disease who are not suitable for Coronary Bypass Surgery.This case demonstrates that by staging the revascularization procedure into three stages, we successfully optimized the patient's coronary arteries to aid in our future stage procedures.In this case, treating the RCA CTO facilitated the subsequent retrograde PCI to the LAD which would otherwise have not been possible.Staging the case also results in shorter more tolerable procedure times and reduced risk of contrast nephropathy for our patient.
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