A 62-year-old male, known diabetic, hypertensive, hyperlipidemia, presented with recurrent epigastric discomfort with sweating and giddiness 3 months duration. Troponinswere negative. Presently exertional angina class ii-iii. HR 67 bpm;130/80 mmhg.
ECG showed QS inferolateral leads, LVH, SR.
Echo- IW RWMA, EF 55%.
Was started on DAPT outpatient 4 weeks earlier, Atorvastatin, Metformin, Bisoprolol, Isordil SR and GTN prn.
Approach-Femoral; Sheaths -6F arterial and venous;Pharmacotherapy- UFH 5000 units; Guide-JR 3.5 guide;Wires- Fielder FC [0.8 gm/0.014] thenPilot 50 [1.5 gm/0.014]used to cross the lesion using 1.2 balloon support, was unable to cross RPLoriginand placed in RPDA. CTO lesion and mid lesion dilated using 2 x 15 mm balloon ;2.25 x 20 mm NC at 14-16 atms. To enter RPL, contralateral access and LCA inj. done Progress 40[4.8gm/0.012] negotiated, but was sub intimal. De-escalated to Fielder FC wire and negotiated the true lumen.
Additional 2000 UFH given (70 Kg-total 100U/kg); Dilated RPL, distal and mid lesions with 2.5 x 15 mm NC balloon at 20 atms. 2.5 x 28 mm DES at 14 atms deployed distal RCA -RPL acrossRPDA 2.5 x 38 mm DES at 16 atms deployed in distal RCA overlapping with previous stent + post dilated the overlap segment at 16 atms Further Post dilation with 3 x 15 mm NC balloon at 18 atms. There was slow flow in RPL stent, but was patent, post stent there was donor vessel thrombosis.IC Tirofiban bolus 25 mic/kg + NTG/Verapamil/Adenosine given with restoration of flow.ACT checked was 288 seconds. Additional 2000 UFH IV given. The contralateralLCA catheter was removed.3 x 34 mm DES at 16 atms deployed in mid to proximal RCA overlapping with previous stent and post dilated overlap segment with same balloon at 16 atms +post dilated distal stent with 2.75 x 15 NC at 16-20 atms with TIMI3 flow and no residual thrombus.
This case highlights many important issues during AWE CTO intervention.
1. The importance of understanding the coronary anatomy and collateral pathway forante grade wire technique.
2. Even though it appeared short length CTO, Dual Inj. Needed to avoid subintimal passage of wire.
3. Parallelwire technique was used to cross to RPDA/RPL with dual injection to facilitate crossing.
4. Even though, ACT was adequate, donor vessel thrombosis occurred which indicates that the contralateral catheter has to be removed when its purpose is served.
5. The excess of intracoronary equipment is associated with stasis in the vessels. That is, the contralateral catheter kept in opposite coronary artery may cause relative stasis in the vessels and cause thrombosis.
6. Otherdilemma is whether patients on maintenance clopidogrel therapy need to be reloaded with high dose clopidogrel before elective procedure.