Case 5: IVUS guided PCI in acute coronary syndrome (NSTEMI)
A 65-year-old male with CCS Class IV chest pain, elevated troponin with peak of 1.5 ng/mL, and EKG with massive anterior T wave inversions transferred from OSH to our hospital. He has initially presented with shortness of breath, chest pressure and progressed to respiratory failure requiring intubation and mechanical ventilation due to volume overload and CHF exacerbation. Echocardiography showed reduced left ventricular wall motion with ejection fraction of 25%.
Although emergency coronary angiography showed no significant stenosis in the RCA, there was densely calcified 60-70% stenosis at the proximal LAD. Further estimation was done with IVUS. This showed attenuated plaque distal to the circumferential calcified lesion, which were considered to be the culprit lesion.
Angio Pre CRA run4
Pre LAD IVUS
Following the diagnosis, PCI was performed. The lesion was pre-dilated with a 3.0mm scoring balloon and a 3.5mm non-compliant balloon up to 15atm pressure. Then a 4.0mm x 12mm DES was deployed at the proximal LAD. The stent was post-dilated with a 4.0mm NC balloon up to 18 atm pressure. Repeat IVUS showed good stent expansion and no stent edge dissection, with the MSA of 9.7mm2.
Post LAD IVUS
In acute coronary syndromes, it is important to secure blood flow and assess the morphology by IVUS. IVUS can help the evaluation of thrombus that are difficult to identify by angiography alone, and in some cases, thrombus diagnosed by angiography may actually be calcification or plaques. In this case, there was an area in the LAD that appeared hazy on angiography and thought to be thrombus, but IVUS confirmed that it was actually a calcified plaque and a lipid plaque.