Case History
 

This 47 yr old diabetic individual had class II –III angina for the past 2 yrs. Risk factors were moderate hypercholestomia & moderate hypertension.

His coronary angiography showed critical diffused lesion in RCA midsegment. The circ-OM showed two tandem lesions critical in nature.

The LAD showed long band osteal lesion of about 7-8mm in length followed by another diffused long lesion in the mid seg of LAD artery.

 

Strategy

Drug eluting stents to RCA, CIRC-OM, Osteal LAD and mid seg LAD

 

Procedure

Since there were 3 lesions in the left system and one simple lesion in the RCA it was decided to complete the RCA lesion first. Although opinions may vary and difficult lesion like LAD might be addressed first.

We had a strong reservation about addressing the osteal LAD first. The reason is Despite the best efforts osteal stent when placed in LAD may project into the left main and may make entry to the circumflex artery very difficult if not impossible and therefore it may be reasonable to address the circ-OM second and finally the LAD.

 

Investigation Reports: Refer to the below videos.

 

Conclusion

In diabetic individual with diffused multivessel disease drug eluting stents could be a suitable option based on the evidences available.

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6F Judkins right guiding catheter is coaxially placed into the RCA and BMW wire was maneuvered across the lesion and parked distally beyond the PL branch. Direct stenting was done using 3 x 23 mm long drug eluting stent directly without prior balloon dilatation.

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Shows direct stent placement of the stent across the lesion.

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Excellent final result is obtained with 0 percent residual stenosis.

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An extra backup 6F guiding catheter was used to intubate the left main and BMW wire is advanced.

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2.5x28mm drug eluting stent was placed directly without prior balloon dilatation into circ-OM lesion.

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Note: the stent has been placed to cover the diseased seg of the circ-OM.

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Shows final good results after stenting.

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The guide catheter has been deeply intubated into the left main. BMW wire is passed through both the lesions ie, mid seg LAD and osteal LAD & parked distally into LAD. 2mm of balloon is seen placed across the mid seg LAD lesion. Note: it significantly blocked the blood flow into the LAD.

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3mm stent is deployed fully across the lesion.

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Shows excellent final result with 0 percent residual stenosis.

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LAO caudal view (spider view) Profile the proximal osteal lesion very distinctly. After balloon dilatation with 2.5x12mm maverick balloon the stent was positioned accurately, covered the LAD ostium, taking due care that stent does not protrude too much in the left main.

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Note: that the 3x18mm stent is placed to cover the LAD from the ostium and the distal end of the stent overlapping the proximal portion of the previous stent placed in the mid.

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Excellent dilatation of the proximal LAD lesion with less than 5 percent residual stenosis.

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RAO caudal view showing all 3 stents (circ-OM lesion stent, mid seg LAD and osteal LAD) with satisfactory results.

Source

Cardiovalens/cvd_demo/cvd/abmcase.htm - Dr.A.B Mehtha's case