Clinical Information
A male, 62 years old came with angina pectoris.

Last February 2017 he had exercise stress test and the result showed positive ischemic response with moderate risk. Coronary angiography showed CTO at LCx with retrograde flow, 50% stenosis at mid RCA and subtotal occlusion at posterolateral branch of RCA, so DES 2.75/18 mm was implanted at PL branch.

Now he came again and complained of chest pain since the first procedure and getting worse for the last few weeks.  ECG showed same result as previous ECG. We suspected that there was progression of stenosis at mid RCA or restenosis at PL stent so we sent him to cathlab and performed coronary angiography.

The angiography showed patent stent and non significant stenosis at RCA and from LCx angiography we saw flow from proximal to distal which we thought there was no total occlusion as we saw at previous procedure.

Procedure

We continued to do LCx stenting, but when we tried to pass through Samurai RC guidewire it failed. We changed it to Fighter guidewire but still it did not work. Then we used 1.8F Finecross microcatheter, unfortunately after several attempts and used different angle the guidewire always went to non intracoronary route. We tried different guidewire, Marvel, but it's also went to the same direction so we decided to put the wire at that route and used another guidewire, Samurai RC and microcatheter to pass the lesion and after several attempts we finally succeeded.

 

Then we predilated distal to proximal LCx using compliance balloon, Maverick 2.0/20 mm, continued with predilatation using noncompliance (NC) balloon Quantum Maverick 2.5/15 mm since it was calcified lesion. But after we evaluated the angiography, we suspected dissection and shifting plaque at osteal of Obtuse marginal (OM) branch. We tried to evaluate from different angle and decided to perform bifurcation stenting with DK Crush technique.

First we deliver Samurai guidewire to side branch, followed by predilatation at osteal OM using Maverick 2.0/20 mm. Then we placed Quantum Maverick 2.5/15 balloon at main vessel facing osteal of side branch after delivered DES Xience 2.25/12 mm at osteal side branch. The stent was deployed with little protrusion to main vessel. We pulled out ex-stent balloon and wire from side branch and crushed stent strut at main vessel using Quantum balloon. Then we rewired distal side branch but unfortunately the balloon could not pass through the stent strut, so we tried to crush again the protruded stent and tried to rewired again using different wire, Samurai RC, and smaller compliance balloon Tazuna 1.25/10 mm. We succeeded to dilate the balloon and open strut stent, and continued with dilatation using bigger size balloon using Maverick 2.0/20 mm at main vessel to side branch then performed first kissing balloon using Quantum balloon at main vessel.

Then we pulled out guidewire and balloon from side branch again, continued with implantation of DES Promus 2.5/28 mm at main vessel. We performed POT technique at proximal part of main vessel stent using NC balloon Quantum Maverick 2.75/12 mm, then placed it at distal LCx and continued with rewiring to side branch using Samurai guidewire, but again it's quite difficult so we changed it to Runthrough NS guidewire. We succeeded to deliver Tazuna balloon and once again opened the stent strut to side branch, continued with dilatation bigger size of balloon Maverick 2.0/20 mm, then dilated NC Quantum Maverick 2.75/12 mm balloon at main vessel and finally performed final kissing balloon. The final result was quite satisfying, no thrombus nor dissection with TIMI 3 flow. This procedure completed after 3 hours, with 70 minutes fluoro time, 250 cc contrasts.  and  using 1 microcatheter, 8 guidewires, 2 compliance balloons, 2 NC balloons, and 2 DES