PCI in complex LM lesions

with NSTEMI and class IV CHF

Dr. Ji-Hung Wang Associate Professor Tzuchi University, School Of Medicine Director of Cardiology Division Tzuchi General Hospital,Hualien,Taiwan.

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Patient profile

*2017-03-01 admitted to Chest ward

# 1 pneumonia Tx: Curam

# 2 poor appetite , general weakness

#3 Constipation, abdominal distension, change of bowel habit, epigastric pain

03-10 colonoscopy: colon cancer (Pathology : adenocarcinoma) pT2N0M0

03-14 septic shock (Blood culture *2 : Escherichia coli)

* 03-14 MICU

EKG : Afib with RVR

03-16 Troponin I #1 0.06, #2 0.21

03-16~03-20 GI ward

*04-16Admitted to Colon Rectal Surgical ward

*04-17 Laparoscopic right colectomy

Brief history

*04-18 SICU

Chest tightness (02:30AM), with dyspnea

Supportive care for multiple

comorbidity

*4/19 Recurrent Chest tightness

call for help again

High TIMI risk, recurrent ischemia complicated with wide QRS tachycardia and uncontrolled class IV CHF

Diagnostic CAG

Diagnostic CAG

Diagnostic CAG

Strategy after CAG

• CABG for high Syntax score:BUT

s/p BK. PAOD s/p bypass graft on both iliac ,DM foot-

bil.,CKD with AKI,acute class IV CHF etc comorbidity

• Transcatheter therapy-how to do?:

1.Critical ostial LM lesions-poor ischemic tolerance High risk for complex procedure.

2.Severe intracoronary calcification in LM to pro-LAD

Simple PCI procedure-impossible.

3.Mechanical circulation supporting devices

High complication-Bil.severe PAOD.

PCI Trying to dilate LAD lesions

with 2.0-12 mm Mini-trek but

failure to pass through

Volcano IVUS

to evaluate LM

IVUS finding

Finally strategy after IVUS

#.Fixed ostial LM lesions first-direct stenting

#.Staging Rota-debulking from Distal LM

to pro-LAD.

#.Stent to LAD cross LM

PCI

4.0-13 mm DES Fixed lesions with NC

PCI Exchange to rota floppy wire

by microcatheter

1.75 rota burr start debulking

with speed 150000 but failure

Rota-Debulking I Speed increase to 170000

But still failure to pass through Speed increase to 180000

Rota-Debulking II

Postdilatation IVUS

Final CAG after stenting with

3.5-48 mm DES

Finally CAG II

Final IVUS

Full PCI course

*Total x-ray exposure:

Total :4414mgy.

*Dye use:

Total 130 cc.

*Total procedure time:

78 minutes.

*4/22 SICU

Mild dyspnea; No chest tightness/pain

*4/23 SICU transfer to

general ward and discharge two weeks later

Plavix 75mg/tab (Clopidogrel) QD 1 tab Bokey 100mg/cap (Acetylsalicylic Acid) QD 1 cap Robestar 10mg/tab (Rosuvastatin) QD 1 tab coxine 20mg/tab (Isosorbide-5-mononitrate) BID 0.5 tab Cordarone 200mg/tab (Amiodarone HCl) QD 1 tab Uretropic 40mg/tab (Furosemide) QD 1 tab Aldactin 25mg/tab (Spironolactone) TID 1 tab

TAKE HOME MESSAGE

• Fixed high-risk but simple lesions

first ,then do complex lesions is a

important strategy in PCI to complex CAD.

• Rotablator make severe calcified complex

lesion to became simple.The sooner you

use the more secure and better.

• Intravascular images is important in

complex PCI

Thanks you for your attention !