SWP

A 53-year-old man with recurrent chest pain at rest (CCS class IV) was referred to our cath. lab. for urgent PCI, with coronary risk factors: hypertension, uncontrol DM and CKD on hemodialysis. Physical exam was unremarkable.

ECG and echocardiogram showed anterior wall ischemia and hypokinesis, respectively, with LVEF 39%. Six months prior to the presentation, a PCI of calcified LM-LAD-LCx with rotablation was done and 4 DES were implanted. 

Coronary angiography revealed a critical in-stent restenosis (ISR) in distal LM bifurcation with 1,1,1 Medina classification, while a borderline stenosis in distal RCA. 

He was proceeded to PCI at the LM bifurcation. A floppy wire was inserted to LM-LAD while a 1.5x15 mm semi compliant (SC) balloon has been placing on the wire. The balloon was then quickly moved to the LM-LAD critical stenosis and then inflated. Another floppy wire was inserted to LM-LCx and the SC balloon was then inflated. RA (Rotablator, Boston) was then performed with a 1.75 mm burr gradually advanced at 150,000 rpm to passed the subsequent lesions of LM-LAD and LM-LCx. Furthermore, a 2.5x15 mm scoring balloon was used to prepare the lesions.  Drug-coated balloons (DCB), 3.5x20 mm and 2.5x20 mm, were deployed at the LM-LAD and LM-LCx, subsequently, and followed by a kissing balloon inflation using those balloons in the bifurcation. Final angiogram showed no residual stenosis and TIMI 3 flow. During the procedures, the patient was experienced an acute lung edema and relieved by medications. He had no any symptom at 12 months follow up post PCI.

PCI of a critical ISR in LM bifurcation in a patient with angina CCS class IV and a low LVEF was successfully done with a quick balloon dilatation followed by rotablation and finalized with kissing DCB inflation.