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Case 20: Complex Multivessel PCI in a High SYNTAX Score

Case Presentation

  • A 74-year-old man presented with class II angina and stress MPI done as pre-op for renal transplant evaluation, revealed moderate multivessels ischemia (apical, inferior and infero-lateral).
  • Coronary angiogram revealed calcified 3 V CAD and LVEF 55%. He was evaluated by CTS and had Heart team discussion; then declined CABG.
  • Medical History: Controlled Hypertension, Hyperlipidemia, ESRD on HD, Diet controlled DM
  • Medications : Aspirin, Atorvastatin, Metoprolol XL, Lisinopril, Amlodipine
  • Angoigram revealed 3 V CAD: 80% long calcified mid RCA, 100% RCA-AV cont, subtotal calcified long segmental mid-distal LAD, 60% D1, 80% LCx-OM2, 80% LCx-LPL, LVEF 55% and Syntax score 33.
  • Planned for high risk multivessel PCI with appropriate use of imaging, rotational atherectomy and Impella LV assist as deemed necessary.

Angiogram

Case Review and Planning

PCI Strategy

  • Plan to do PCI to LAD
  • With the presence of long calcified lesion in LAD, may require adequate lesion modification (i.e., Rotational atherectomy).
  • Initial wire choice: Fielder/FineCross
  • Second wire choice: Gaia series and MiracleBros

STEPS

  • We first used Fielder (non-tapered polymer jacketed tip) with FineCross microcatheter. However Fielder didn’t cross the calcified lesion.
  • Then we switched to Gaia 3 (tapered, hydrophilic coating, composite core with 1:1 torque) and able to navigate through the calcific LAD lesion.
  • Exchanged to Rota wire via FineCross microcatheter.
  • Rota ablation was performed with 1.5 Burr, followed by PTCA and two DES (3.5/38 and 3/18 mm) placement in mid and distal LAD.

Wiring Technique

Final Angiogram

Learning Points

  • Composite core technology, used in Gaia series, enables to perform an excellent 1:1 torque control, compared to a traditional one.
  • Composite core consists of dual core and dual coil with multiple wire components to enhance durability and torque transmission.
  • We used Gaia 3 wire in this case and able to perform very fine movement to negotiate the subtotal long calcific lesion while providing an additional support via a microcatheter.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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