A patient with 3-vessel disease declined CABG and was referred for mutivessel PCI. He had severe lesions in the distal RCA, proximal and distal LAD, proximal circumflex and the distal left main. Radial access was challenging due to small radial artery size, but eventually using a Glidewire catheters were advanced to the aorta. Despite using 5 French catheters the patient developed severe radial spasm and access was changed to femoral.
A 5 French JR4 guide was used to engage the RCA. Stent delivery was challenging, but eventually succeeded after deeply intubating the guide catheter almost all the way to the lesion. The stent was underexpanded at 12 atm, but fully expanded after postdilation at 20 atm.
Treating the LAD lesions was challenging due to poor antegrade flow during attempts to place stents. This was overcome by withdrawing the stent into the guide catheter, injecting contrast and then advancing the stent.
The proximal circumflex was stented. The patient had a distal left main trifurcation. Provisional stenting was performed in the distal left main by deploying a stent from the left main into the LAD. Following POT, the circumflex and ramus were assessed with a pressure wire: dPR was 0.98 and 0.91, respectively, hence a decision was made to not perform additional stenting.
Final angiogram after guidewire removal showed a filling defect in the proximal LAD stent. ACT was 280 and the patient was given 600 mg of clopidogrel at the beginning of the case. Eptifibatide was administered. Rewiring was challenging due to the recently placed left main stent, but was eventually achieved using a reversed (“hairpin”) guidewire. IVUS confirmed a filling defect, likely thrombus, that resolved after Penumbra thrombectomy. There was deformation of the left main stent that was treated with implantation of another ostial stent and postdilation with an Ostial Flash balloon, with a nice final result.
21 окт 2024
