Case Presentation: More than Meets the Eye
Yogesh Jonna, University of Illinois at Chicago, Chicago, IL
Yogesh Jonna, University of Illinois at Chicago, Chicago, IL
Keywords: Acute Coronary Syndromes (ACS), Chronic Total Occlusion (CTO), Complex and High-risk Coronary Intervention (CHIP) and Hemodynamic Support
Title
:
More Than Meets the Eye
Introduction
:
An 83 year old male presented with NSTEMI and acute decompensated heart failure, found to have LM to proximal LAD severe stenosis as well as severely calcified RCA lesions, with newly reduced LVEF to 25%. He was turned down for CABG, so referred for pVAD-assisted PCI.
Clinical Case:
pVAD was placed,
RCA was wired, then orbital atherectomy performed followed by deployment of two DES in the ostial to mid RCA. Angiogram of the left system showed worsening stenosis (now sub-totally occluded ostial LAD) with TIMI-2 flow. Antegrade wiring was attempted with use of multiple wires and microcatheters without success due to an aneurysm in the LCx and very early takeoff septal branch. After significant effort and contrast use limitations due to CKD as well as wire dissection, decision was made to stop procedure. pVAD was removed, patient was allowed to recover for a few days and was brought back for short re-attempt at antegrade wiring with stiffer wires (unsuccessful) followed by retrograde wiring from the RCA. Retrograde wiring to the LAD distal to the severely stenosed segment was successful, and “Tip-In” technique was used to externalize the wire, followed by balloon angioplasty and stenting.
Discussion
:
This case shows the utility of CTO techniques that may be helpful in cases where antegrade wiring is unsuccessful such as this case where severe stenosis with angulation made antegrade wiring very difficult. We also discuss use of hemodynamic support during high-risk complex PCI.