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TCTAP C-139 To Cover or Not to Cover
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S227
Readmitted D15 for subacute stent thrombosis Lesson to learn: most edge dissection on OCT is benign, exception to this is presence of IMH associated with edge dissection, progression of IMH will lead to acute or subacute stent thrombosis.
Case Summary. I experienced the case that the IVUS catheter stuck and is difficult to remove. When the IVUS is caught, it is important to be conscious of the stent struts, to confirm with the IVUS how the previous stent was placed. TCTAP C-139 To Cover or Not to Cover Ka Lung Chui1 1 Prince of Wales Hospital, Hong Kong, China [CLINICAL INFORMATION] Patient initials or identifier number. TLY Relevant clinical history and physical exam. A 79 years old female. Known history of HT, hyperlipidemia, IHD Cath in 2003: LM normal, mLAD 30%, dLCx 60%, occluded PLV for medical treatment Admitted for recent onset of exertional chest pain, relieved by rest and TNG PE Blood pressure stable CVS dual heart sound, no murmur Chest clear. Relevant test results prior to catheterization. ECG showed LBBB (old) Relevant catheterization findings. Cardiac cath showed pLAD 70%, dLCx 60%, dRCA into PDA subtotal occlusion, PLV CTO. [INTERVENTIONAL MANAGEMENT] Procedural step. IL3.5 guide to RCA Fielder XT crossed the lesion, exchanged Rinato wire using finecross Predilated with 2.0 then followed by DEB to RCA Same IL3.5 guide to LAD Rinato to dLAD Predilated with 2.5 mm balloon Followed by DES 3.0 x 38 to p-mLAD Angiogram showed satisfactory angiographic result OCT showed proximal edge dissection with IMH, decided to leave at that time
S228
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
1. A SAL1 guiding catheter to engage RCA orifice. 2. The Fielder FC wire via the Minnie micro catheter could not pass the RCA critical lesion. 3. We used the balloons (1.5 mm and 2.5 mm) to dilate the proximal RCA and used the parallel wire technique but still failed to pass the lesion. 4. The angiography showed collateral vessels from left circumflex artery (LCX) to RCA. 5. We tried retrograde approach from LCX; a Sion wire and one Sion Blue wire alternatively within a Corsair micro catheter were used. 6. The Sion wire crossed the collateral’s and passed through the critical RCA lesion by retrograde approach. 7. We changed the wire to RG3 for externalization and the Fielder FC wire to RCA. 8. The stents (3.0 mm and 2.5 mm) were deployed at proximal to distal RCA after the balloon angioplasty. 9. The final angiorgraphy showed good results with RCA TIMI 3 flow
Case Summary. This case illustrated that presence of IMH in edge dissection may cause acute or subacute stent thrombosis. This needed to be covered if presence. Imaging guidance should be used to guide the stent size and stent length. In general, a longer stent should be selected in order to cover the entry point of the hematoma. Moreover, stent should be deployed at moderate pressure to avoid squeezing of hematoma on both sides. TCTAP C-140 Retrograde Rescue for Antegrade Dissection Cheng-Yu Ko,1 Cheng-Han Li1 1 National Cheng Kung University Hospital, Taiwan [CLINICAL INFORMATION] Patient initials or identifier number. Tsai Relevant clinical history and physical exam. This 70-year-old male had the history of coronary artery disease status post coronary artery bypass graft, diabetes mellitus, hypertension and dyslipidemia. He complained of effort related dull chest pain since 3 months ago, which got more frequent for 3 weeks. No referred pain or dyspnea. On physical examination, a surgery scar was on his chest. Otherwise, he was hemodynamically stable and other physical examinations were unremarkable. Relevant test results prior to catheterization. The hemogram and biochemistry tests were unremarkable. The electrocardiography revealed sinus rhythm and old inferior wall myocardial infarction; the chest x ray disclosed surgical wire retention. The echocardiogram showed preserved left ventricular systolic function but mild inferior wall hypokinesis. The Thallium scan revealed viable and non-viable tissue in the inferior wall. Relevant catheterization findings. The 1st coronary angiography revealed coronary artery disease with triple vessel disease post coronary artery bypass graft; left internal mammary artery to left anterior descending artery failure and one saphenous vein graft to right coronary artery (RCA) failure. The RCA was diffuse atherosclerotic with about 60% stenosis at orifice, a long segmental lesion up to 90% stenosis at proximal and middle part and about 50% stenosis at distal part. 2nd: critical stenosis and one aneurysm at the RCA. [INTERVENTIONAL MANAGEMENT] Procedural step. The 1st attempt 1. A SAL1 guiding catheter to engage right coronary artery (RCA) orifice. 2. The Fielder FC wire was used but severe dissection with TIMI 1 flow was noted when crossing the critical stenosis. 3. The Fielder FC wire could not enter the true lumen. A Run through hyper coat wire as the parallel wire technique but failed. 4. A Ultimate Bros 3 wire via the Fine cross micro catheter still could not enter the true lumen. 5. To avoid worsened dissection, we closed the procedure. The patient was hemodynamically stable then. The 2nd attempt (2 months later because the angina got more frequent. Critical stenosis and one aneurysm at the RCA)
S227
Readmitted D15 for subacute stent thrombosis Lesson to learn: most edge dissection on OCT is benign, exception to this is presence of IMH associated with edge dissection, progression of IMH will lead to acute or subacute stent thrombosis.
Case Summary. I experienced the case that the IVUS catheter stuck and is difficult to remove. When the IVUS is caught, it is important to be conscious of the stent struts, to confirm with the IVUS how the previous stent was placed. TCTAP C-139 To Cover or Not to Cover Ka Lung Chui1 1 Prince of Wales Hospital, Hong Kong, China [CLINICAL INFORMATION] Patient initials or identifier number. TLY Relevant clinical history and physical exam. A 79 years old female. Known history of HT, hyperlipidemia, IHD Cath in 2003: LM normal, mLAD 30%, dLCx 60%, occluded PLV for medical treatment Admitted for recent onset of exertional chest pain, relieved by rest and TNG PE Blood pressure stable CVS dual heart sound, no murmur Chest clear. Relevant test results prior to catheterization. ECG showed LBBB (old) Relevant catheterization findings. Cardiac cath showed pLAD 70%, dLCx 60%, dRCA into PDA subtotal occlusion, PLV CTO. [INTERVENTIONAL MANAGEMENT] Procedural step. IL3.5 guide to RCA Fielder XT crossed the lesion, exchanged Rinato wire using finecross Predilated with 2.0 then followed by DEB to RCA Same IL3.5 guide to LAD Rinato to dLAD Predilated with 2.5 mm balloon Followed by DES 3.0 x 38 to p-mLAD Angiogram showed satisfactory angiographic result OCT showed proximal edge dissection with IMH, decided to leave at that time
S228
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
1. A SAL1 guiding catheter to engage RCA orifice. 2. The Fielder FC wire via the Minnie micro catheter could not pass the RCA critical lesion. 3. We used the balloons (1.5 mm and 2.5 mm) to dilate the proximal RCA and used the parallel wire technique but still failed to pass the lesion. 4. The angiography showed collateral vessels from left circumflex artery (LCX) to RCA. 5. We tried retrograde approach from LCX; a Sion wire and one Sion Blue wire alternatively within a Corsair micro catheter were used. 6. The Sion wire crossed the collateral’s and passed through the critical RCA lesion by retrograde approach. 7. We changed the wire to RG3 for externalization and the Fielder FC wire to RCA. 8. The stents (3.0 mm and 2.5 mm) were deployed at proximal to distal RCA after the balloon angioplasty. 9. The final angiorgraphy showed good results with RCA TIMI 3 flow
Case Summary. This case illustrated that presence of IMH in edge dissection may cause acute or subacute stent thrombosis. This needed to be covered if presence. Imaging guidance should be used to guide the stent size and stent length. In general, a longer stent should be selected in order to cover the entry point of the hematoma. Moreover, stent should be deployed at moderate pressure to avoid squeezing of hematoma on both sides. TCTAP C-140 Retrograde Rescue for Antegrade Dissection Cheng-Yu Ko,1 Cheng-Han Li1 1 National Cheng Kung University Hospital, Taiwan [CLINICAL INFORMATION] Patient initials or identifier number. Tsai Relevant clinical history and physical exam. This 70-year-old male had the history of coronary artery disease status post coronary artery bypass graft, diabetes mellitus, hypertension and dyslipidemia. He complained of effort related dull chest pain since 3 months ago, which got more frequent for 3 weeks. No referred pain or dyspnea. On physical examination, a surgery scar was on his chest. Otherwise, he was hemodynamically stable and other physical examinations were unremarkable. Relevant test results prior to catheterization. The hemogram and biochemistry tests were unremarkable. The electrocardiography revealed sinus rhythm and old inferior wall myocardial infarction; the chest x ray disclosed surgical wire retention. The echocardiogram showed preserved left ventricular systolic function but mild inferior wall hypokinesis. The Thallium scan revealed viable and non-viable tissue in the inferior wall. Relevant catheterization findings. The 1st coronary angiography revealed coronary artery disease with triple vessel disease post coronary artery bypass graft; left internal mammary artery to left anterior descending artery failure and one saphenous vein graft to right coronary artery (RCA) failure. The RCA was diffuse atherosclerotic with about 60% stenosis at orifice, a long segmental lesion up to 90% stenosis at proximal and middle part and about 50% stenosis at distal part. 2nd: critical stenosis and one aneurysm at the RCA. [INTERVENTIONAL MANAGEMENT] Procedural step. The 1st attempt 1. A SAL1 guiding catheter to engage right coronary artery (RCA) orifice. 2. The Fielder FC wire was used but severe dissection with TIMI 1 flow was noted when crossing the critical stenosis. 3. The Fielder FC wire could not enter the true lumen. A Run through hyper coat wire as the parallel wire technique but failed. 4. A Ultimate Bros 3 wire via the Fine cross micro catheter still could not enter the true lumen. 5. To avoid worsened dissection, we closed the procedure. The patient was hemodynamically stable then. The 2nd attempt (2 months later because the angina got more frequent. Critical stenosis and one aneurysm at the RCA)