By Dr. Arnav Kumar MD, MSCR
Interventional Cardiologist
HCA Medical Center Hospital
Houston, Texas
87 year old extremely pleasant, active woman was sent to us for complex LM PCI . She has distal left main 70% disease, ostial LAD 70% disease, calcific 90% disease of the proximal high Obtuse marginal artery and 99% Proximal LCX disease.
The left main itself is very long and anomalous. We anticipated challenge in delivering equipments across the retrofelxed LCX.
Additionally, she has distal RCA disease . She was felt to be too high risk for CABG due to advanced age We were able to cross the ostial LAD – lesion using a sion blue wire. We were able to cross the high OM lesion using a minamo wire.
Crossing the 99% very calcified proximal left circumflex lesion proved challenging. However, we were able to cross it using Fielder XT.
Retroflexed LCX, anomalous long LM have high risk of stent dislodgment left main dissection and wire dislodgement.
The plan was to do double cush- however, no stent would go across the LCX lesion.
We first pre dilated LM, LAD, LCX, ON lesions. We did encounter challenges in delivering balloons into LCX.
After Predilation, we placed a stent in the OM and crushed it with a ballon placed in LM-LCX. However we faced extreme difficulty in placing stent in the LCX-LM.
Finally, we had to take out both the OM and the LAD wire and were successful in delivering the stent across the LXC lesion using guideliner support (advancing the guideliner in to the LCX).
After deploying the stent In the LM-LCX, we post dilated with an NC balloon.
We quickly crossed back into the the LAD – ie switched to a coullote technique..
Final angiograms demonstrated excellent stent expansion, no edge dissection and no geographic miss.
Impella was taken out at the end of the procedure and LFA was perclosed. Patient underwent PCI of RCA two days later and discharged home In great spirits
Extremely retroflexed LCX – showing that all stents started prolapsing- unable to deliver; Had to sacrifice LAD, OM wires to advance a guideliner into the LCX… and hence was able to place a stent into the LCX-LM. However this meant that we had to change to coullote technique; Placed a stent in the LAD – LM
Then simultaneous kissing balloon inflation of the LAD-LM-LCX
Final POT
GlobeMedic 