CASE20210824_001

Nonagenarian with a Complex Left Coronary System

By Jonathan Fang Jonathan Fang, Frankie CC Tam
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Presenter

Jonathan Fang

Authors

Jonathan Fang Jonathan Fang1, Frankie CC Tam2

Affiliation

Queen Mary Hospital Hong Kong, Hong Kong, China1, Queen Mary Hospital, Hong Kong, China2
DES / BVS - Stents (bare-metal, drug-eluting)

Nonagenarian with a Complex Left Coronary System

Jonathan Fang Jonathan Fang1, Frankie CC Tam2

Queen Mary Hospital Hong Kong, Hong Kong, China1, Queen Mary Hospital, Hong Kong, China2

Clinical Information

Patient initials or Identifier Number

WS

Relevant Clinical History and Physical Exam

91 year-old man with hypertension.presents with chest pain for 2 hoursECG:  inferior STEMIKillip class IV with cardiogenic shock given inotropic support Taking to the cath lab for primary PCI. Done to RCA thrombotic occlusion Echo global HK EF 30%. Mild MR Patient still has unstable angina symptoms with chest pain  minimal exertion CCS III-IV after PPCI to RCAStaged procedure to left coronary system was performed after 5 days

Relevant Test Results Prior to Catheterization

Troponin T (Roche) elevated ~18000ng/L ECG inferior STE precordial reciprocal change pRCA 100% thrombotic occluasion with PPCI done with 2.25/12 DSE, 2.5/22 DES and weaned off inotorpe 

Relevant Catheterization Findings

left side dLM 90% disease. LAD Subtotal occlusion. LCx diffuse critical disease. Ramus tandem lesions 80% 

Interventional Management

Procedural Step

7 Fr LFA, 6FR RRA access. 
LFA 7Fr, RRA 6Fr7Fr XB LAD 3.5 as GC to LM. TRAP 3.5 from RRATurnpike 135cm as MC. LAD CTO crossed with Fielder XTA, exchange to SION blueLAD dilated with 2.0 balloon and IVUS donemLAD dilated with NC 2.75, stent with ultimaster 2.25/38, post dilate NC 2.25 and NC 2.75Runthrough NS to OM and IVUS done: severe luminal stenosis at OM and LCX ostiumOM POBA 2.0, stent with Coroflex 2.0/24, post dilate NC 2.25 at 20 atmwire to LCX. IVUS cannot crossedmLCX Ca and undilatable lesion, POBA with NC 1.5, NC 2.0 and NC scoreflex 1.75 at 24 atmIVUS doneLCX stent with Ultimaster 2.5/33LM-LAD-LCX (minicrush stenting)LCX stent with Ultimaster 2.5/24, crused with MB NC 3.5LM-LAD stent with Ultimaster 3.5/24, POT NC 4.0 at 16 atm, post dilate NC 3.5LCX rewired with Fielder XTA (on Crusade MC)LCX os POBA 2.0 balloon and NC 3.0KBI (NC 3.5/NC 3.0 at LAD/LCX)IVUS to LAD and LCX showed good results. TIMI 3 flow to all vessels

Case Summary

Age alone should not be a contraindication for revascularization in complex high-risk indicated procedures (CHIP) In nonagenarians with complex coronary artery disease, CHIP intervention with including LM bifurcation is feasible