Simplicity is Beauty
Dr. Tak-Shun CHUNG
A 69-year-old gentleman with history of diabetes and hyperlipidemia was admitted for inferior ST-segment elevation myocardial infarction two months ago with ad-hoc primary percutaneous coronary intervention (PCI) done to right coronary artery (RCA). This time he was admitted for staged PCI to left coronary artery (LAD) (Movie 1, Movie 2). The proximal LAD calcified lesion at D1 bifurcation was predilated with 2.5x15mm NC balloon at 8atm (Movie 3, Movie 4). The lesion was pre-assessed with optical coherence tomography which showed ostial LAD MLA 4.4mm2(Figure 1).
It was decided for dedicated bifurcation stenting using NilePax 3.0x24mm, and therefore LAD and D1 were wired. However, much difficulty was encountered while attempting to advance the stent into the lesion. It was suspected due to crisscrossing of the guidewires. While attempting to remove the stent, some stickiness was encountered, and fluoroscopy reviewed that stent was dislodged in proximal LAD (Movie 5, Movie 6). Retrieval was attempted with 4.0mm Microsnare and 2.0 balloon (Movie 7, Movie 8) but all were unsuccessful. Eventually the stent remained in LM, in order to avoid further damage to LM, it was decided to deploy the half Nilepax in LM and crushed the other half with another stent in proximal LAD (Movie 9, Movie 10). It was done in stepwise manner with 2.5, 3.0, 3.5mm NC balloon. IVUS was used to pre-assess the extent of lesion and test the passage. Then mid LAD was stented with DES 3.0x 30mm overlapped proximally with another DES 4.0×30 from LM to LAD. It was post dilated with 4.0 NC balloon at 20atm and then 4.5 NC balloon at 20 atm. Post procedure OCT still showed the crushed stent in pLAD (Figure 2). This case was planned for prolonged DAPT in view of substantial stent material in proximal LAD.
First thanks for nicely handling of critical complication.On hindsight have you done FFR of LAD proximal lesion as angiographically does not look significant