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TCTAP C-235 Intravascular Ultrasound Guided Percutaneous Coronary Intervention in a Left Anterior Descending Artery Chronic Total Occlusion
S388
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
[INTERVENTIONAL MANAGEMENT] Procedural step. Thrombus aspiration (Thrombuster III, Kaneka) andballoon angioplasty using 3.25 15mmballoon were performed. Finally, TIMI 3 flow was obtained with intra-aorticballoon pumping (IABP) and this session was finished. Early follow-up CAG 2days after the procedure showed TIMI 3 flow and no residual stenosis orthrombus but peri-stent contrast staining (PSS) in the stenting lesion.Subsequently, OCT and intravascular ultrasound (IVUS) was performed. OCTrevealed several obvious uncovered struts, thrombus, and late stent malappositionsafter EES implantation. IVUS revealed expansive vessel remodeling at the siteof stent malapposition. No additional procedure was performed and IABP wasremoved that day. He had continued dual antiplatelet therapy with prasugrel plusaspirin after the admission. He had no chest pain and discharged 16 days afterthe procedure.
TCTAP C-235 Intravascular Ultrasound Guided Percutaneous Coronary Intervention in a Left Anterior Descending Artery Chronic Total Occlusion Debdatta Bhattacharyya,1 Ayan Kar,2 Debdatta Majumder2 1 Rabindranath Tagore International Institute of Cardiac Sciences, India; 2 NH-RTIICS, India [CLINICAL INFORMATION] Patient initials or identifier number. JP Relevant clinical history and physical exam. A 63 year old diabetic, hypertensive female patient presented with exertional angina. On examination pulse was 60 beats / min, all peripheral pulses were palpable with no anaemia, jaundice sign, edema or clubbing, with JVP. Blood pressure was 140 / 90 mmHg. Chest was clear & heart sound was normal with no murmur. Relevant test results prior to catheterization. ECG showed ST depression in V4 to V6, Echocardiogram shows good ejection fraction of 69% with normal valves and no chamber enlargement. Haemoglobin was 11.6 gm / dl. FPS was 116 mg /dl. HbA1C was 7. Blood urea 30 mg / dl, serum creatinine was 1.04mg/ dl. Total Cholesterol was 160 mg /dl, LDL cholesterol was 90 mg / dl and Triglyceride was 120 mg /dl. Relevant catheterization findings. LMCA: Normal LAD: Totally occluded in the proximal segment LCx: 30-40% stenosis in the distal segment RCA: Normal PDA: supplies extensive collaterals to LAD territory
Case Summary. In conclusion, VLST in this case was caused by obvious very late acquired stent malapposition with expansive vessel remodeling revealed by OCT and IVUS 19 months after everolimuseluting stent implantation into sirolimus-eluting stent.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
[INTERVENTIONAL MANAGEMENT] Procedural step. The left coronary artery was engaged with XB 3.5 7Fguide catheter. An appropriately shaped Run Through intermediate wire wasnegotiated through the CTO with back up support of a balloon catheter. Theprogress of wire was guided by retrograde visualization of the LAD by RCAinjection. Once the wire was confirmed to be in the distal LAD, serialpre-dilatations with 1.5X6mm and 2X15 mm balloons @ 10-14 atmospheres werecarried out. Thereafter the IVUS (Boston ATLANTIS pro) catheter was introducedinto the LAD and the transducer was positioned in that part of the distal LADwhich was adjudged to be the landing zone of the distal stent by angiography.An IVUS pull back was done right up to the ostium of LAD from this distallanding zone and serial measurements were taken of the diameter of the LAD(Inner lumen diameter in the distal landing zone and media to media at multiplepoints of the mid and proximal LAD). Thereafter high pressure balloondilalatations were with 2.5 X12mm balloon at mid and proximal LAD. Stenting wasdone to the mid LAD with a 2.5 X16 mm Promus Element Plus stent followed byimplantation of a 3.0X38mm Promus Element in the proximal LAD. This wasfollowed by serial post dilatations with 2.5X12mm balloon distally up to 16atmospheres and 3.5X12mm balloon @ 18 atmospheres in the proximal LAD. The procedure was completed after a final IVUS run to ensure that the stentstruts were completely apposed and well expanded along the course of the LAD.
S389
Case Summary. CTO in femalediabetics are difficult subset of patients with disappointing long term resultdespite initial successful angioplasty. These vessels often appear to be verysmall caliber by angiography. PCI guided solely by angiography results in undersizing of stents which translates to high TVF rates. It is a well-known factthat if we can achieve MLA >7mm2 with drug eluting stents thelong term outcomes are excellent. In this case IVUS guidance helped us toachieve an MLA >7mm2 in the proximal LAD which would have beenimpossible to achieve if sit was solely guided by angiography.
TCTAP C-236 Where Does Ischemia Come from: Macro or Micro? Min Jeong Kim,1 Bon-Kwon Koo1 Seoul National University Hospital, Korea (Republic of)
1
[CLINICAL INFORMATION] Patient initials or identifier number. SW Song Relevant clinical history and physical exam. 57 years old male was admitted due to the abnormal finding on cardiac ammonia-PET scan. He was asymptomatic and had medical history of ischemic stroke and stent implantation at LAD in 2007. Risk factors: DM, CKD (stage 3), ischemic stroke, previous PCI history Physical exam: regular hear beat without murmur, clear breath sound
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
[INTERVENTIONAL MANAGEMENT] Procedural step. Thrombus aspiration (Thrombuster III, Kaneka) andballoon angioplasty using 3.25 15mmballoon were performed. Finally, TIMI 3 flow was obtained with intra-aorticballoon pumping (IABP) and this session was finished. Early follow-up CAG 2days after the procedure showed TIMI 3 flow and no residual stenosis orthrombus but peri-stent contrast staining (PSS) in the stenting lesion.Subsequently, OCT and intravascular ultrasound (IVUS) was performed. OCTrevealed several obvious uncovered struts, thrombus, and late stent malappositionsafter EES implantation. IVUS revealed expansive vessel remodeling at the siteof stent malapposition. No additional procedure was performed and IABP wasremoved that day. He had continued dual antiplatelet therapy with prasugrel plusaspirin after the admission. He had no chest pain and discharged 16 days afterthe procedure.
TCTAP C-235 Intravascular Ultrasound Guided Percutaneous Coronary Intervention in a Left Anterior Descending Artery Chronic Total Occlusion Debdatta Bhattacharyya,1 Ayan Kar,2 Debdatta Majumder2 1 Rabindranath Tagore International Institute of Cardiac Sciences, India; 2 NH-RTIICS, India [CLINICAL INFORMATION] Patient initials or identifier number. JP Relevant clinical history and physical exam. A 63 year old diabetic, hypertensive female patient presented with exertional angina. On examination pulse was 60 beats / min, all peripheral pulses were palpable with no anaemia, jaundice sign, edema or clubbing, with JVP. Blood pressure was 140 / 90 mmHg. Chest was clear & heart sound was normal with no murmur. Relevant test results prior to catheterization. ECG showed ST depression in V4 to V6, Echocardiogram shows good ejection fraction of 69% with normal valves and no chamber enlargement. Haemoglobin was 11.6 gm / dl. FPS was 116 mg /dl. HbA1C was 7. Blood urea 30 mg / dl, serum creatinine was 1.04mg/ dl. Total Cholesterol was 160 mg /dl, LDL cholesterol was 90 mg / dl and Triglyceride was 120 mg /dl. Relevant catheterization findings. LMCA: Normal LAD: Totally occluded in the proximal segment LCx: 30-40% stenosis in the distal segment RCA: Normal PDA: supplies extensive collaterals to LAD territory
Case Summary. In conclusion, VLST in this case was caused by obvious very late acquired stent malapposition with expansive vessel remodeling revealed by OCT and IVUS 19 months after everolimuseluting stent implantation into sirolimus-eluting stent.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
[INTERVENTIONAL MANAGEMENT] Procedural step. The left coronary artery was engaged with XB 3.5 7Fguide catheter. An appropriately shaped Run Through intermediate wire wasnegotiated through the CTO with back up support of a balloon catheter. Theprogress of wire was guided by retrograde visualization of the LAD by RCAinjection. Once the wire was confirmed to be in the distal LAD, serialpre-dilatations with 1.5X6mm and 2X15 mm balloons @ 10-14 atmospheres werecarried out. Thereafter the IVUS (Boston ATLANTIS pro) catheter was introducedinto the LAD and the transducer was positioned in that part of the distal LADwhich was adjudged to be the landing zone of the distal stent by angiography.An IVUS pull back was done right up to the ostium of LAD from this distallanding zone and serial measurements were taken of the diameter of the LAD(Inner lumen diameter in the distal landing zone and media to media at multiplepoints of the mid and proximal LAD). Thereafter high pressure balloondilalatations were with 2.5 X12mm balloon at mid and proximal LAD. Stenting wasdone to the mid LAD with a 2.5 X16 mm Promus Element Plus stent followed byimplantation of a 3.0X38mm Promus Element in the proximal LAD. This wasfollowed by serial post dilatations with 2.5X12mm balloon distally up to 16atmospheres and 3.5X12mm balloon @ 18 atmospheres in the proximal LAD. The procedure was completed after a final IVUS run to ensure that the stentstruts were completely apposed and well expanded along the course of the LAD.
S389
Case Summary. CTO in femalediabetics are difficult subset of patients with disappointing long term resultdespite initial successful angioplasty. These vessels often appear to be verysmall caliber by angiography. PCI guided solely by angiography results in undersizing of stents which translates to high TVF rates. It is a well-known factthat if we can achieve MLA >7mm2 with drug eluting stents thelong term outcomes are excellent. In this case IVUS guidance helped us toachieve an MLA >7mm2 in the proximal LAD which would have beenimpossible to achieve if sit was solely guided by angiography.
TCTAP C-236 Where Does Ischemia Come from: Macro or Micro? Min Jeong Kim,1 Bon-Kwon Koo1 Seoul National University Hospital, Korea (Republic of)
1
[CLINICAL INFORMATION] Patient initials or identifier number. SW Song Relevant clinical history and physical exam. 57 years old male was admitted due to the abnormal finding on cardiac ammonia-PET scan. He was asymptomatic and had medical history of ischemic stroke and stent implantation at LAD in 2007. Risk factors: DM, CKD (stage 3), ischemic stroke, previous PCI history Physical exam: regular hear beat without murmur, clear breath sound