Case Title
Negotiating the odds in complicated lesions
Case History
A 49 year old diabetic and hypertensive gentleman with chronic stable angina, with a positive stress test at low workloads.
This patient has a Chronic Total Occlusion (CTO). He has several odds against a successful plasty:
- Plenty of bridging collaterals
- Central lumen not clearly visible
- Side branch coming out at the site of obstruction
- Acute proximal tortuousity in the mid segment.
Investigation Reports
Click on the thumbnail images to see the videos |
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Jr guide catheter seated co-axially quite well.
Jr6 catheter was selected as we thought these kind of lesions do require deep throating. Moreover, there was some suggestion of a central channel which was thought to be explored |
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Options at this point:
Change of wire?
Take another wire by the side of this wire?
Take a balloon support?
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We took another wire hoping that the 1st wire will produce an exit block and the 2nd wire may slip into the main channel. Unfortunately that also did not work. |
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Since the main channel itself was curved and extremely tight the 2nd wire was also slipping into the side branch.
Options now:
Change the wire to miracle/cross it?
Take a balloon support?
Go to over the wire system?
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We decided to take over the wire system and thinnest possible balloon, mercury –O (JOMED) which is supposed to be guaranteed for crossing.
Balloon seemed to have crossed very partially.
Note: Guide catheter has been deep throated and the wire has slipped out into the balloon |
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Shows mild daughtering effect of the proximal half of the mildangulated channel. |
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Both balloon and wire have been re introduced. Notice significant proximal tortuousity, choice PT ES wire into side branch, and that 1.5mm balloon has crossed the lesion and gone into side branch.
Now it was thought that a low pressure balloon dilatation might create a passage and one would be able to torque the wire towards the main channel easily. Although there is a risk that there may be a total occlusion of the main channel leading to acute IWMI.
Notice Some staining Of RCA proximal to the total occlusion |
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1.5mm balloon inflated at 6-7atm |
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Some widening of the channel is seen with better filling of the main vessel. |
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The channel is sufficiently widened. |
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Notice how easily the wire could be advanced into the main channel |
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2.5mm balloon was easily advanced through the tight stenosis, distal marker positioned distal to the stenosis |
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Smooth dilatation of the main channel and the side branch is seen. |
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3x18 mm des fully expanded upto 16atm. |
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Very Gratifying Final Result |
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Bifurcating lesion LAD, DIAG then addressed using EBU guide catheter. |
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2 wires in position.
Bifurcation balloon advanced. notice multiple markers |
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Guide catheter backs out as the lesion is unable to be crossed. |
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Finally, bifurcation balloon at the site of lesion |
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Notice tight waist in the main vessel and DIAG Ostium. |
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Inadequate result. |
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Interesting points:
- Required high pressure in one of the vessels to dilate it fully, at the cost of penalising the 2nd vessel by subjecting it to unnecessary high pressure.
- Main proximal stem was getting overdistended & penalised & therefore good, old technique of sequential dilatation of individual vessels was adopted.
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The diagonal was sufficiently dilated and notice des in place in main vessel. The idea was to resort to provisional stenting |
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Excellent result of proximal LAD with mild pinching of diagonal branch |
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Vein graft stenosis-the current trends. May 03, 2004
Optimal measures for LIMA Interventions. Apr 24, 2004
An Approach to Bifurcation Lesion Apr 10, 2004
Negotiating the odds in complicated lesions Mar 18, 2004
Focal stenting in a complicated LAD lesion Mar 4, 2004
An approach to an extremely tortuous RCA distal lesion Feb 11, 2004
Nightmare in Cathlab Jan 6, 2004
An approach to markedly tortuous lesion. Dec 24, 2003
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Treatment of instent restenosis. Nov 15, 2003
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Complex angioplasty in tortuous vessels. Oct 16, 2003
Angioplasty & Stenting in tortuous vessels. Oct 1, 2003
60 yr. Old man with a History of Multiple Coronary Grafts Sep 15, 2003
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Courtesy
Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.
Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com
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