Case 165: Manual of PCI - NSTEMI in an elderly patient

An 89-year-old woman presented with NSTEMI and was found to have distal left main disease along with stenoses in the proximal/mid LAD and the left main. Wiring the circumflex was challenging due to angulation but was eventually successful using a Samurai RC wire. The LAD was also wired with a workhorse wire. A Sasuke dual lumen microcatheter was used to advance a guidewire into the first obtuse marginal branch that had a severe ostial stenosis. The OM1 was predilated. Attempts to deliver a 2.5x26 mm Orsiro to the circumflex lesion failed due to angulation, even after using a buddy wire and a guide extension. A Wiggle wire was inserted into the circumflex using the Sasuke microcatheter followed by successful stent delivery and deployment. There remained significant ostial disease in the OM1 but it could not be rewired and the patient did not have any chest pain or ECG changes, hence it was left as is. The LAD and left main were stented with DES jailing the circumflex (provisional stenting) with a nice final result.

[@matheuscsmed]

Thank you, Matheus Silva

[@abaiturdubaev4105]

Perfect as always, maestro👏🏻

[@shangz0216]

Thanks for the excellent case presentation.

[@fatherabdul]

Super work as always Manos 🎉you always teach us something new… 🌴🌴

[@cristianolisi3001]

Well done, good work.

[@pranomc]

Is there an edge dissection in the Left main stent?

[@sachindev220]

Sir is there any edge dissection in LMCA?

[@user-ku9lm2ic1i]

Hello. It`s very interesting case. A have one question. Why did the LM show a diameter 5 mm on IVUS, but POT 4mm?

[@nisennananem]

5.19 was the minimal lumen area, not the diameter. He didn't show a normal reference diameter in the IVUS run, but probably the normal diameter in the left main was 4mm, considering his choice for the POT

[@mahmoud_elrayes]

Excellent approach.What is your opinion regarding stenting from proximal to distal in case of LM / LAD long lesion to precisely adjust LM stent then go for LAD stent ? Thanks

[@atefkhamis7286]

Great

[@NikhilJha89]

Excellent case
Will you do ffr in rca?
Deb for smaller om?
Can we use two different stent brands in same patient?