Case 1 – LM PCI

Case Presentation

A 75-year-old female presented with left sided chest pain at rest concerning for unstable angina.
Medical history: CAD s/p CABG x 4 (2001) [LIMA-LAD, SVG-OM2, SVG-D1, occluded SVG-RCA], Severe AS s/p TAVR (CoreValve 29mm), atrial fibrillation on anticoagulation, HFrEF (EF 33%), PAD, HTN, and HLD.

Prior coronary angiogram was done by using JL 3.5 for left system, AR 2 for right system and showed severe left main disease with complete total occlusion of proximal RCA.

Coronary angiogram was performed by using JL 3.5 but not able to do selective engagement.

Then we changed to FL 3.5 guide catheter and revealed severe disease in LM.

Graft angiogram showed patent LIMA to distal LAD, SVG to OM and SVG to D1.

FL 3.5 guide catheter and a guide extension catheter (i.e. Guidezilla) were used to engage and performed PTCA with NC balloon 3.0/12. Then DES (Xience 3.0/12) was placed in the left main with good result.

Final angiogram

Learning Points

FL 3.0/3.5 guide catheter can be used to engage the coronary artery if routine JL catheter is not able to engage.
Due to the waist of Evolut/CoreValve, remember to downsize the guide catheter at least “0.5” size.
A guide extension catheter is often useful and provides an additional support for coronary intervention in post TAVR cases.