Bağcılar Education and Research Hospital
A 75-year-old male patient underwent coronary angiography for Acute MI without ST elevation. Right coronary artery was OK (Video 01). There were LMCA osteal plaque, LAD proximal 90% stenosis and LCX with normal anatomy (Video 02). Plan was PCI for LAD at the same session.
LAD osteal has been totally occluded patient’s chest pain begins when wire escalation through the guide catheter followed by the floppy wire and followed by PT-2 (Video 03). Two new operators from outside come in for support. Thereafter, total occlusion was passed through the miracle guide wire (Video 04) and predilatation was performed with 1.5×20 mm and 3.0×15 mm balloons ( Image 01). When the LAD perfusion is TIMI-2, 3.0 x 20 mm DES is planned for dissection (Video 05). In the left cranial view, it is assumed that the path of the LAD is abnormal and the guide wire should be taken at the supposed correct position. The stent position is adjusted (Video 06). The stent opens at 16 ATM ( Image 02). When the post-procedure perfusion is weak (Video 07), the wire position is tried to be restored. The stent balloon opens at 4 ATMs where it is supposed to be LAD (Video 08). After ballooning, intramyocardial and epicardial rupture are detected. The guide wire does not seem to be in the lumen (Video 09). The balloon is retracted and opened at 4 ATMs in the lumen of proximal LAD, and the time-saving process bring us some time to control previous angiography ( Image 03). Operator attempted to reintroduce guide wire in to true lumen (Video 10). The wire position is checked and a 2.5×20 balloon is dilated at 4 atm to try to close the rupture ( Image 04). Although the balloon is dilated three times for 6 minutes and it does not leak while the balloon is dilated, however, it continues when the balloon is deflated (Video 11). On top of this, the 2,8×19 mm grafted stent is dilated at 16 atm after stent position is adjusted (Video 12). It seems that leakage have been completely covered (Video 13). A 3.0×24 DES is placed between the proximal stent and the grafted stent (Video 14). The stent is dilated for 30 seconds at 18 ATMs. Distal postdilatation with a stent balloon is performed ( Image 06). Except for distal embolization, satisfactory results are obtained (Video 14, Video 15). Later, 9 mm pericardial fluid was detected on ECHO. No cardiac tamponade developed during and after the procedure.
You need to be very gentle during wire escalation.
Each case can be much more complex than a routine PCI, and even more.
Since the operating doctor prevails with previous angiographic views, he should preserve his coolness in complications and participate in joint decisions with newly arrived operators within the team spirit.
The coronary anatomy can surprise us, we have to go back and examine the old views before changing the guidewires. If we are unsure of the guide, we should check with the other methods that we are in the lumen or continue with the smaller balloon and lower pressure.
When it’s even worse, we should fight coldly until the end.
From the Mineapolis Heart Institute, the following educational videos of Manos Brilakis expert in the CTO interventions mention the ping-pong method. A second guide catheter and guidewire are placed for balloon exchange or uploading a grafted stent to minimize pericardial cavity to be filled by huge amount of blood to prevent cardiac tamponade. Absolutely watch … video