Case 6 – Thrombotic LAD PCI

Case Presentation

An 88-year-old male with medical history of Severe AS s/p TAVR (34 mm Evolut-R ), CAD s/p PCIs, and HFpEF presented with angina pectoris.
EKG showed an old LBBB but new ST elevations in the lateral leads. Trop was positive with peaked level of 164.
TTE showed apical and septal hypokinesis with LVEF 35%.

Prior coronary angiogram was done using JL 4 and AR 2 without any difficulty.

Selective right coronary artery angiogram was performed by using JR 4.

FL 3.5 catheter was then used for left coronary angiogram but not able to do selective engagement. Then we attempted by advancing the coronary guide wire first , then railed VL 3 guide catheter over the wire for selective engagement.

A guide extension catheter (i.e. Guidezilla) was used for a better support. The angiogram revealed a thrombotic lesion in proximal LAD.

Successful intervention of mid LAD was performed by using DES (Synergy 2.75/16) with an excellent result.

Learning Points

The catheter choice in post TAVR (EVOLUT valve) is usually FL 3.0/3.5, followed by Ikari right 1.0/1.5.
VL 3 guide catheter can sometimes be used for selective engagement.
The operator should have a low threshold to use guide extension catheter in post TAVR PCI cases.