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TCTAP C-128 LAD CTO Complicated with True Bifurcation Lesion
S216
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. It has been reported a successful PCI to Protected Left Main disease and heavily calcified double CTO using simple wire or hydrophilic wire. Sometimes we need to do Plaque modification or debulking to create origin of native arteries. Procedure was performed successfully without complication and good clinical condition. TCTAP C-127 Treatment of Chronic Total Occlusion of Right Coronary Artery Using an Occluded Venous Graft: 3 Guide Technique 1
Nimit Shah 1 Saifee Hospital, India [CLINICAL INFORMATION] Patient initials or identifier number. GV Relevant clinical history and physical exam. A 69 years-old man had a CABG 18 years ago Admitted with troponin positive ACS LIMA to LAD and venous grafts to RCA and first obtuse marginal. PCI to RCA graft and native LAD was 3 years ago. Non diabetic and being treated for hypertension. Good LV function On standard secondary prevention therapy includingaspirin, clopidogrel and LMWH
TCTAP C-128 LAD CTO Complicated with True Bifurcation Lesion Hui Li,1 Fucheng Sun1 Beijing Hospital, China
1
[CLINICAL INFORMATION] Patient initials or identifier number. yq Relevant clinical history and physical exam. A 70-year old patient was admitted to our hospital for 3 years effort angina. He underwent angiography 2 months ago which showed very severe coronary diseases, he refused CABG and took medicine treatment only. His cardiovascular risk factors included hypertension and hyperlipidemia. Relevant test results prior to catheterization. The ECG showed avL, V4-6 T wave inversion, the level of liver function tests was normal, creatinine of 109umol/L, BUN 4.88mmol/L, NtproBNP of 115.49pg/ml, TnI of 0.08ng/ml. Relevant catheterization findings. We reexamined angiography which showed very severe three-vessel diseases, including middle LAD CTO lesion, left main to proximal LAD moderate lesions 50-75% stenosis, a large diagonal branch near the LAD CTO lesion with a 90% stenosis in the ostium, distal LCX CTO Lesion (small), a 75% stenosis in proximal RCA which provided collateral circulation to distal LAD.
Relevant test results prior to catheterization: Relevant catheterization findings: [Interventional Management] PROCEDURAL STEP. 3. Retrograde approach 4. Hybrid approach Three guide catheters were used Native RCA (8F femoral access, AL 0.75) Native left system (6F Left radial access, EBU 3.5) Venous graft to RCA (6F, right radial access,MPA) Retrograde visualization done from native left system RCA wired retrogradely via SVG with the support of corsair.
Unable to advance corasir, dilatation across the stent struts Retrograde Knuckling Corsair advanced retrogradely 3 guides, antegrade wiring Antegrade wiring; Reverse cart; Wire into the retrograde guide; Unable to advance corsair into the retrograde guide hence Corasir removed Stent advanced retrogradely; Unable to advance the third stent; Guideliner to advance the stent; antegrade wiring and antegrade picture Antegrade wiring to the distal RCA; antegrade stents; Stent across the anastomisis and within the previous stent with the guide liner support; Stent in the ostium; Final result.
CASE SUMMARY. This case highlight complexities of PCI in native vessel CTO’s of patients with Hx CABG. Successful use of both the native conduits and venous grafts, using three guide catheters, to deploy stents in the chronically occluded segment Knowledge and expertise in performing antegrade,retrograde and hybrid approach crucial to the success of CTO’s Patient remained symptom free at 6 months THINK OUTSIDE THE BOX!
[INTERVENTIONAL MANAGEMENT] Procedural step. 1. We selected EBU 3.5 guiding catheter, BMW wire was sent to the vessel D1. 2. Fielder XT wire supported by Fine cross MG could not pass through LAD CTO lesion. 3. Pilot 150 wire passed through LAD CTO with repeatedly trying, then the lesion was dilated with 1.2-12mm and 2.0-20mm balloons. 4. LAD and D1 were checked by IVUS, then we chose to treat the lesions with crush technique. 5. D1 lesion was dilated with 1.2-12 mm balloon. 6. Resolute stent 2.25-18 mm was deployed from distal to middle LAD, then Resolute stent 2.5-24mm deployed from D1 to middle LAD. 7. Balloon crush,then Resolute stent 3.0-30 mm 3.5-24 mm were deployed from middle LAD to LM. After that rewired, kissing and post dilation with NC balloon 8. Angiography showed diffuse stenosis in the distal LAD, IVUS showed severe atherosclerotic lesions, it was dilated with 2.0-20mm balloon, then we used DEB to treat distal LAD lesion and checked IVUS, the result was pretty well. 9. Three months later, the check of angiography showed very good effects for LAD LM and D1.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S217
COMPLICATIONS (TCTAP C-129 TO TCTAP C-163) TCTAP C-129 Nightmare Complication After Percutaneous Coronary Intervention for a STEMI Wei-Chun Huang,1 Chin-Chang Cheng,1 Cheng Chung Hung,1 Cheng-Hung Chiang,1 Guang-Yuan Mar,1 Chun-Peng Liu1 1 Kaohsiung Veterans General Hospital, Taiwan [CLINICAL INFORMATION] Patient initials or identifier number. 198765 Relevant clinical history and physical exam. A 54 years-old retired professional sport men has history of smoking, hypertension, end stage renal disease with regular hemodialysis, diabetes mellitus foot s/p below the knee amputation, previous episode of complete AV block. He had received PTCAþstent for 2 times due to CAD 5 Years ago. Relevant test results prior to catheterization. He suffered from inferior STEMI 2 months ago. At that time, bare metal stent was implanted over middle segment of RCA after removal of thrombus. IABP and temporal pacemarker were implanted due to unstable condition. Fortunately, he was discharge later on. Relevant catheterization findings. Unfortunately, he suffered from chest tightness again one month ago. Angiography showed massive thrombus within and after previous stent with a small aneurysm formation over middle segment of RCA. After thrombus removal, a drug-eluting balloon was used to treat the in-stent thrombus lesions. [INTERVENTIONAL MANAGEMENT] Procedural step. However, he suffered from fever and chillness off and on for 1-2 month and visited our emergent department. Vital signs: BP: 112/50 mmHg, PR: 88/min, RR: 24/min, BT: 37.6 C. A Gr 2 systolic murmur over apex was found. Blood culture showed GPC in group. After antibiotics was prescribed, trans-esophageal echo showed fresh vegetation(with high embolic potential) attached at right atrium anterior wall endocardium (near right coronary artery middle stented segment) and right coronary artery middle stented segment is focally dilated with vascular wall thickening, the possibility of regional and segmental mycotic aneurysm. Three-dimension CT showed suspected myotic aneurysm over RCA. After 4 weeks antibiotic treatment, coronary angiography revealed instent restenosis with a huge aneurysm over middle part of RCA and poor distal run off. Operation arranged and huge pseudoaneurysm found over RCA. After open the aneurysm, a kinking and tortion of metallic stent was noted. Removal of pseudoaneurysm and by pass surgery were done. The patient received continuous antibiotics treatment.
Case Summary. 1. Even some patients cannot accept the treatment of CABG, PCI still can be helpful for them, we should choose right strategy and technique. 2. How to choose CTO wire, from Fielder XT to Pilot 150. 3. CTO with bifurcation Lesion was quite complex, but we still finished PCI procedures step by step. 4 De novo lesions of small vessels can be treated with DEB, the effect of treatment was really good.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. It has been reported a successful PCI to Protected Left Main disease and heavily calcified double CTO using simple wire or hydrophilic wire. Sometimes we need to do Plaque modification or debulking to create origin of native arteries. Procedure was performed successfully without complication and good clinical condition. TCTAP C-127 Treatment of Chronic Total Occlusion of Right Coronary Artery Using an Occluded Venous Graft: 3 Guide Technique 1
Nimit Shah 1 Saifee Hospital, India [CLINICAL INFORMATION] Patient initials or identifier number. GV Relevant clinical history and physical exam. A 69 years-old man had a CABG 18 years ago Admitted with troponin positive ACS LIMA to LAD and venous grafts to RCA and first obtuse marginal. PCI to RCA graft and native LAD was 3 years ago. Non diabetic and being treated for hypertension. Good LV function On standard secondary prevention therapy includingaspirin, clopidogrel and LMWH
TCTAP C-128 LAD CTO Complicated with True Bifurcation Lesion Hui Li,1 Fucheng Sun1 Beijing Hospital, China
1
[CLINICAL INFORMATION] Patient initials or identifier number. yq Relevant clinical history and physical exam. A 70-year old patient was admitted to our hospital for 3 years effort angina. He underwent angiography 2 months ago which showed very severe coronary diseases, he refused CABG and took medicine treatment only. His cardiovascular risk factors included hypertension and hyperlipidemia. Relevant test results prior to catheterization. The ECG showed avL, V4-6 T wave inversion, the level of liver function tests was normal, creatinine of 109umol/L, BUN 4.88mmol/L, NtproBNP of 115.49pg/ml, TnI of 0.08ng/ml. Relevant catheterization findings. We reexamined angiography which showed very severe three-vessel diseases, including middle LAD CTO lesion, left main to proximal LAD moderate lesions 50-75% stenosis, a large diagonal branch near the LAD CTO lesion with a 90% stenosis in the ostium, distal LCX CTO Lesion (small), a 75% stenosis in proximal RCA which provided collateral circulation to distal LAD.
Relevant test results prior to catheterization: Relevant catheterization findings: [Interventional Management] PROCEDURAL STEP. 3. Retrograde approach 4. Hybrid approach Three guide catheters were used Native RCA (8F femoral access, AL 0.75) Native left system (6F Left radial access, EBU 3.5) Venous graft to RCA (6F, right radial access,MPA) Retrograde visualization done from native left system RCA wired retrogradely via SVG with the support of corsair.
Unable to advance corasir, dilatation across the stent struts Retrograde Knuckling Corsair advanced retrogradely 3 guides, antegrade wiring Antegrade wiring; Reverse cart; Wire into the retrograde guide; Unable to advance corsair into the retrograde guide hence Corasir removed Stent advanced retrogradely; Unable to advance the third stent; Guideliner to advance the stent; antegrade wiring and antegrade picture Antegrade wiring to the distal RCA; antegrade stents; Stent across the anastomisis and within the previous stent with the guide liner support; Stent in the ostium; Final result.
CASE SUMMARY. This case highlight complexities of PCI in native vessel CTO’s of patients with Hx CABG. Successful use of both the native conduits and venous grafts, using three guide catheters, to deploy stents in the chronically occluded segment Knowledge and expertise in performing antegrade,retrograde and hybrid approach crucial to the success of CTO’s Patient remained symptom free at 6 months THINK OUTSIDE THE BOX!
[INTERVENTIONAL MANAGEMENT] Procedural step. 1. We selected EBU 3.5 guiding catheter, BMW wire was sent to the vessel D1. 2. Fielder XT wire supported by Fine cross MG could not pass through LAD CTO lesion. 3. Pilot 150 wire passed through LAD CTO with repeatedly trying, then the lesion was dilated with 1.2-12mm and 2.0-20mm balloons. 4. LAD and D1 were checked by IVUS, then we chose to treat the lesions with crush technique. 5. D1 lesion was dilated with 1.2-12 mm balloon. 6. Resolute stent 2.25-18 mm was deployed from distal to middle LAD, then Resolute stent 2.5-24mm deployed from D1 to middle LAD. 7. Balloon crush,then Resolute stent 3.0-30 mm 3.5-24 mm were deployed from middle LAD to LM. After that rewired, kissing and post dilation with NC balloon 8. Angiography showed diffuse stenosis in the distal LAD, IVUS showed severe atherosclerotic lesions, it was dilated with 2.0-20mm balloon, then we used DEB to treat distal LAD lesion and checked IVUS, the result was pretty well. 9. Three months later, the check of angiography showed very good effects for LAD LM and D1.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S217
COMPLICATIONS (TCTAP C-129 TO TCTAP C-163) TCTAP C-129 Nightmare Complication After Percutaneous Coronary Intervention for a STEMI Wei-Chun Huang,1 Chin-Chang Cheng,1 Cheng Chung Hung,1 Cheng-Hung Chiang,1 Guang-Yuan Mar,1 Chun-Peng Liu1 1 Kaohsiung Veterans General Hospital, Taiwan [CLINICAL INFORMATION] Patient initials or identifier number. 198765 Relevant clinical history and physical exam. A 54 years-old retired professional sport men has history of smoking, hypertension, end stage renal disease with regular hemodialysis, diabetes mellitus foot s/p below the knee amputation, previous episode of complete AV block. He had received PTCAþstent for 2 times due to CAD 5 Years ago. Relevant test results prior to catheterization. He suffered from inferior STEMI 2 months ago. At that time, bare metal stent was implanted over middle segment of RCA after removal of thrombus. IABP and temporal pacemarker were implanted due to unstable condition. Fortunately, he was discharge later on. Relevant catheterization findings. Unfortunately, he suffered from chest tightness again one month ago. Angiography showed massive thrombus within and after previous stent with a small aneurysm formation over middle segment of RCA. After thrombus removal, a drug-eluting balloon was used to treat the in-stent thrombus lesions. [INTERVENTIONAL MANAGEMENT] Procedural step. However, he suffered from fever and chillness off and on for 1-2 month and visited our emergent department. Vital signs: BP: 112/50 mmHg, PR: 88/min, RR: 24/min, BT: 37.6 C. A Gr 2 systolic murmur over apex was found. Blood culture showed GPC in group. After antibiotics was prescribed, trans-esophageal echo showed fresh vegetation(with high embolic potential) attached at right atrium anterior wall endocardium (near right coronary artery middle stented segment) and right coronary artery middle stented segment is focally dilated with vascular wall thickening, the possibility of regional and segmental mycotic aneurysm. Three-dimension CT showed suspected myotic aneurysm over RCA. After 4 weeks antibiotic treatment, coronary angiography revealed instent restenosis with a huge aneurysm over middle part of RCA and poor distal run off. Operation arranged and huge pseudoaneurysm found over RCA. After open the aneurysm, a kinking and tortion of metallic stent was noted. Removal of pseudoaneurysm and by pass surgery were done. The patient received continuous antibiotics treatment.
Case Summary. 1. Even some patients cannot accept the treatment of CABG, PCI still can be helpful for them, we should choose right strategy and technique. 2. How to choose CTO wire, from Fielder XT to Pilot 150. 3. CTO with bifurcation Lesion was quite complex, but we still finished PCI procedures step by step. 4 De novo lesions of small vessels can be treated with DEB, the effect of treatment was really good.