Complex Cases in Interventional Cardiology

Case Study: Successful Reattempt of Percutaneous Coronary Intervention (PCI) in a 45-Year-Old Male with Chronic Total Occlusion of the Left Anterior Descending Artery (LAD).

Patient Profile:

A 45-year-old male patient with a recent history of Acute Coronary Syndrome (ACS) was referred for reattempted Percutaneous Transluminal Coronary Angioplasty (PTCA) after a previously failed intervention for a chronic total occlusion (CTO) of the Left Anterior Descending (LAD) artery. The patient presented with a regional wall motion abnormality (RWMA) in the LAD territory, mild left ventricular (LV) dysfunction, and hemodynamic stability at admission.

Initial Diagnosis and Failed Attempt:

A coronary angiogram conducted at an outside hospital revealed:

· Double vessel disease.

· A 100% mid-LAD chronic total occlusion.

· A non-dominant left circumflex artery (LCx) treated with medical management.

The previous attempt to revascularize the LAD through PTCA was unsuccessful, leading to the decision to reattempt the procedure.

Complexity of the Case:

This case presented several technical challenges, including:

Absence of outflow: The target vessel exhibited poor distal outflow, complicating the procedure.

Calcified lesion: The lesion was heavily calcified, increasing procedural difficulty.

Lesion length: An expected lesion length of over 20 mm, adding to the complexity.

J-CTO score: A J-CTO score of 3, indicating a very difficult CTO lesion.

Proximity of side branch: The proximity of a side branch near the main vessel’s CTO lesion posed a risk of the guidewire slipping into the side branch during the intervention.

Tandem type calcific lesion: A tandem calcified lesion made crossing the distal portion particularly challenging.

Intervention Technique:

The decision was made to proceed with an antegrade approach to cross the CTO lesion. Initially, routine workhorse wires failed to cross the lesion due to the wire repeatedly slipping into the side branch. However, success was eventually achieved using a specialized CTO wire (GAIA 1) with small balloon support and rotational maneuvers.

Innovations and Challenges in the Procedure:

The intervention faced considerable difficulties, especially in dealing with the calcified nature of the distal lesion and the tandem nature of the blockage. Key procedural steps included:

Proximal lesion crossing: The proximal portion of the lesion was crossed and pre-dilated with a 1.5 x 12 mm non-compliant (NC) balloon.

Calcific tandem lesion: The distal lesion, being heavily calcified, proved extremely difficult to cross and dilate. Repeated cycles of pre-dilation were performed using balloons of increasing sizes (1.5 x 12 mm, 2 x 12 mm, 2.5 x 16 mm NC balloons).

Stenting: Two overlapping drug-eluting stents (DES) were placed— a 2.5 x 40 mm stent for the mid-LAD and a 3 x 36 mm stent for the distal LAD. This was followed by post-dilation with a 3.5 x 12 mm NC balloon to ensure optimal expansion.

Final Outcome: After the intervention, TIMI III flow was successfully restored, indicating normal blood flow through the previously occluded LAD.

Conclusion:

This case highlights the challenges and complexities of treating chronic total occlusions, particularly in cases with calcific lesions and poor distal vessel outflow. Despite the initial failure of the PTCA, the reattempt using advanced wire techniques, repeated balloon pre-dilatations, and overlapping DES implantation resulted in a successful intervention. This underscores the importance of persistence and innovation in the management of complex coronary lesions, ultimately leading to favorable clinical outcomes.