Huge LM Thrombosis during Antegrade PCI for LCX-CTO
Dr. Po-Ming KU
Chi-Mei Medical Center, Taiwan
A 68 years old man presented with angina for coronary angiography which showed severe triple disease including CTO in mid LCX (Figure 1, Figure 2). Patient opted for PCI with total 10,000 units of heparin given and 6Fr JL guiding catheter was engaged into LM. LCX CTO was attempted with Crusade support and IVUS guiding (Figure 3). Patient developed severe chest pain with shock and angio check showed LM clot with poor flow in LAD and LCX (Movie 1, Movie 2). IABP was inserted to support the hemodynamic condition. Clot suction with Pronto catheter was attempted. However, despite sucking out small clot, the TIMI flow and hemodynamic state were not improved (Figure 4). The ACT was 100 seconds and a bolus of 10,000 units of heparin was given. The TIMI flow was still poor despite repeated episodes of dilatation with 2.5mm balloon (Movie 3).
7Fr EBU catheter was then engaged to LM for direct negative suction which successfully sucked out a big clot (Figure 5). The TIMI flow was improved afterwards. LCX CTO was attempted again after hemodynamic condition being stabilized. Despite of parallel wiring technique, the wire could not pass to distal true lumen. The procedure aborted because of contrast load (>300ml contrast). The final angiogram showed TIMI 3 flow in LAD (Movie 4, Movie 5).
This case illustrated the importance of ACT check before attempting a complex PCI and the feasibility of using guiding catheter as suction catheter in bail out situation.