A tale of LAD and RCA CTO complicated by a thrombus in OM: Patience holds the key
Presenter
Atul Kaushik, MD, FSCAI, All India Institute of Medical Sciences, Jodhpur, Jodhpur, Rajasthan, India
Atul Kaushik, MD, FSCAI, All India Institute of Medical Sciences, Jodhpur, Jodhpur, Rajasthan, India and Sourabh Goswami, All India Institute of medical sciences, Jodhpur, India
Keywords: Chronic Total Occlusion (CTO)
Title: A tale of LAD and RCA CTO complicated by a thrombus in OM: Patience holds the key
Introduction: Chronic total occlusions (CTO) are always challenging and difficult for per cutaneous interventions. These procedures often require difficult manipulation and modification of techniques like side branch wiring for support, buddy wire technique, side branch balloon etc. to support guides and catheters for successful negotiations and outcomes. However, despite careful monitoring these may often lead to complications like thrombus formation, side branch occlusion etc. One should be prudent and careful while tackling these complicated lesions.
Clinical Case: - 62-year-old male with previous history of acute coronary syndrome IWMI 8 months back
- Angina on effort III for last 6 months.
BP= 130/80 mm Hg PR= 78/min ECG: Q waves in II, III, aVF. ECHO: Normal LV size, RWMA in basal septum and inferior wall , mild MR , LVEF=48 %. Diagnostic angiogram: LCA: LM short and dividing into LAD and LCx LAD ostial 100 %stenosis (CTO), LCx : free of significant disease, RCA : ± 100 % block, Both LAD and RCA filling retrogradely through contralateral collaterals Management plan: PCI to LAD and RCA CTO PCI to LAD for guide support needed a wiring in LCx because of lack of guide support. Wire escalated from runthrough intermediate to GAIA III which could negotiate the lesion however it was complicated by thrombus formation in LCx. Patient remained asymptomatic without ECG changes. Thrombus in LCx was managed with thrombosuction followed by balloon dilatation followed by GP IIb/IIIa infusion. Check Angio after 48 hours revealed no residual thrombus in OM. PCI to RCA was done successfully.
Discussion: PCI to CTO is always challenging especially when encountered with chronic total occlusions of more than one coronary artery. Operators often need to apply techniques like side branch wiring for goof guide support while handling these cases. Duw to prolonged procedural times these cases may often get complicated with thrombus formation in native vessels. However, one should remain focused and and may think of conservative measures while handling these situations.