Case Title

Focal stenting in a complicated LAD lesion

Case History

84 yrs old lady with no risk factors developed recurrent angina and left ventricular failure. She also is found to have carcinoma of vagina with a spread to the rectum. This made her unfit for surgery or as a least preffered option.

Investigation Reports

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In view of her poor left ventricular function pulmonary artery monitoring accomplished with right coronary catheter Notice that the left main is upgoing. There is heavy calcification of left main pratically entire LAD and circumflex. The right coronary is totally occuluded and receives copious collaterals from the septal branches of LAD and some from circumflex. Culprit artery was LAD and from symptomatic relief point of view it was deceided to address only the LAD artery and observe her subsequently. This was in view of renal dsyfunction and advanced state of malignancy. 3.5 extra back up support catheter was positioned outside the left main in the background note right catheter into the pulmonary artery and the pacing catheter in the right ventricle. Over the wire balloon technicque after placing the wire in to the LAD, balloon was brought upto the mid LAD The wire was removed and ROTA wire was advanced through the proximal end of the balloon. The whole calcified segment was rotablated with 1.25mm burr. This shows that there is no evidence of no flow or slow flow Same over the wire ninja 2mm balloon was threaded over the ROTA wire. ROTA wire was removed and stabiliser plus wire was positioned to distal part of the LAD. Shows sequential dilatation of the artery with 2mm balloon. An attempt was made to pass 2.5mm drug eluting stent Taxus-TM Boston Scientific but it could not negotiate down the LAD because of extremely heavy calcification. Therefore 2.5x19 and 2.5x16 coroflex were deployed sequentially and overlapping to cover the mid segment of the LAD. Since it was not does only the tightest spots were covered with the stent. Excellent results of LAD stent.

Discussion

On this 84 year old lady who had advanced malignancy and who was suffering from recurrent LVF with unstable angina was identified to have severe critical lesions in LAD with heavy calcification as culprit vessel. Here minimum intervention to relieve symptoms is needed. Moreover she also had diminished renal function.

When you are not using drug eluting stent restenosis rate in stented segment is propotionate to the length of the stent particularly if width of the stent is less than 2.5mm needless to say that in a patient with low ejection fraction like this following steps should be taken.

1. Inta-aoratic balloon support like in this case
2. Premedicate and hydrate the patient well.
3. Use minimum dye
4. Do a focal stenting and try to achieve practical results and not necessarily ideal results.

Courtesy

Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.

Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com