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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.

Left Main DK Crush Video ID