2024 Scientific Sessions

Title
Complicated mini Crush of LAD/D3

Introduction

69 year old man with progressive exertional angina and positive stress test in the anterior and anterolateral wall presented for LAD/D3 PCI using a mini crush technique

Clinical Case

D3 and LAD were pretreated with semi compliant balloons prior to IVUS. The patient became very hypertensive during the procedure (SBP to 220 mmHg) and started complaining of chest pain. No change was noted in the coronary angiography. Nitroglycerin drip was started. IVUS showed concentric calcium in the LAD for which intravascular lithotripsy was performed in both LAD and D3. We then proceeded with stenting using a 2.25 mm DES in D3 and a 3.5 mm DES in the LAD. Prior to the kissing balloon the patient, who had been complaining of chest pain since the beginning of the procedure, became more restless. Repeat angiography showed acute occlusion of D3. Tirofiban was initiated and nitroglycerin drip was increased. We made multiple attempts at re-wiring D3 with a new Whisper wire and an angled micro catheter. Once wire position was obtained, the D3 stent was post-dilated and final kissing balloon was performed. We then noted a small dissection at the distal edge of the LAD stent and deployed a 3.5 x 8 mm stent to cover it. As we were obtaining an LV EDP, the pigtail catheter kinked significantly and could not be straitened with 0.035", 0.018" or 0.014" wire. Ultimately we obtained femoral access and using a gooseneck snare, straightened the catheter that was then removed from the radial sheath

Discussion

Our patient had chest pain since the beginning of the procedure when his BP increased >200 due to anxiety. It was not easy to notice a clinical change when the D3 branch acutely occluded.

Although this was a relatively simple procedure with mini crush technique, complications can happen and significantly prolong the duration of the case. That included very unexpected complications like a faulty pigtail.