CASE20210823_002

CTO Intervention with Minimal Contrast Usage Using Coronary Imaging ( IVUS )

By Vijayendran Rajalingam, Dharmaraj Karthikesan, Saravanan Krishinan, Kantha Rao Narasamuloo, Abd Syukur Abdullah, Mohd Ridzuan Bin Mohd Said, Khor Leet Ming, Chea Chin Yung
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Presenter

Vijayendran Rajalingam

Authors

Vijayendran Rajalingam1, Dharmaraj Karthikesan1, Saravanan Krishinan2, Kantha Rao Narasamuloo1, Abd Syukur Abdullah1, Mohd Ridzuan Bin Mohd Said1, Khor Leet Ming1, Chea Chin Yung1

Affiliation

Hospital Sultanah Bahiyah, Malaysia1, Ministry Of Health Malaysia, Malaysia2
Imaging - Invasive Imaging (IVUS, OCT, spectroscopy, etc)

CTO Intervention with Minimal Contrast Usage Using Coronary Imaging ( IVUS )

Vijayendran Rajalingam1, Dharmaraj Karthikesan1, Saravanan Krishinan2, Kantha Rao Narasamuloo1, Abd Syukur Abdullah1, Mohd Ridzuan Bin Mohd Said1, Khor Leet Ming1, Chea Chin Yung1

Hospital Sultanah Bahiyah, Malaysia1, Ministry Of Health Malaysia, Malaysia2

Clinical Information

Patient initials or Identifier Number

Mr K

Relevant Clinical History and Physical Exam

56 year old Chinese male History Of Bilateral Hydronephrosis with Bilateral proximal Ureteric CalculusBilateral NephrolithiasisPlan for J stenting procedure by Urology Team as part of pre operation optimization he was Referred to Cardiology team in view of ECG Changes ( attached )  Further history complain of reduce effort tolerance off recently o/eBP 145 mmHg/ 70 mmHg PR 89 bpm  lungs clear cvs: no murmur no pedal edema 

Relevant Test Results Prior to Catheterization

ECG : LBBB  , early transition at v3,v4 , inferior axis  
HOLTER : > 30%Supraventricular beats < 1%HR 62 bpm max 111 bpmMax R-R 1.38Ventriculars ( isolated 34566, couplets 24)Bigeminal cycles 80 . 80
ECHO : EF 33%            GLOBAL HYPOKINESIA            RWMA PRESENT 

Relevant Catheterization Findings

LEFT SYSTEM : 
Left Main system normal Proximal LAD 60- 70% stenosis mid LAD CTO with prestenotic aneurysmal  segmentDiagonal 1 ostium 95%  stenosis with post stenotic aneurysmal segment 
Right SYSTEM: 
Ectatic Right Coronary System proximal PLV 80% 

Interventional Management

Procedural Step

Procedural steps : 1)    EBU 3.5 , 7 Fr2)    Wired using  (fine cross with  fielder  XTR  into distal LAD3)    Confirm in true lumen with selective contrast4)    Exchange with sion blue GW5)    Attempt D1 cto using fielder xtr with fine cross6)    Escalate to GIA 1ST cross then exchange with runthrough NS into distal D17)    Predilate mLAD using sapphire 3 2.0 mm x 15 mm  @10 atm (2.13)8)    Predilate d1 also using sapphire 3 ( 2.0 x15mm) 10 ( 2.13)9)    1ST  IVUS  RUN LAD / D110) Scoreflex NS 2.5 x10( mLAD)12 ( 2.50) – 24 ( 2.68)11) Score flex  NC2.5 x10  (D1)  12( 2.50) – 22( 2.65)12) 2ND IVUS run post Scoreflex both vessel13) DEB sequent please Neo 3.5 x 20 over D1 @6(3.5)14)  Stented mLAD with pramus premier 3.5 x 32 10 ( 3.43)  12 ( 3.58 )15) 3rd IVUS ( decide on optimization )16) Post dilate with Sapphire NC PTCA 3.5 x15 20atm ( 3.72 ) – 26 atm (3.89 )17) 4th IVUS18) Post dilate with sapphire II NC PTCA 4.0 x1016atm(4.14 ) – 20atm(4.41)19) 5th IVUS LAD & D1Good stent appositionGood result20) Wire removed good result

Case Summary

Post CAG - No complication total contrast used 45 cc 
Post angiography ECG  : normal sinus rythm ( Resolutions of PVCs ) Repeated HOLTER  PVC burden < 1 %ECHO improved in LV function 40%  
Patient remains well Plan for relook 9 months