Case 83: PCI Manual - Failing all the way to success 3

A patient with 3-vessel disease declined CABG and was referred for mutivessel PCI. He had severe lesions in the distal RCA, proximal and distal LAD, proximal circumflex and the distal left main. Radial access was challenging due to small radial artery size, but eventually using a Glidewire catheters were advanced to the aorta. Despite using 5 French catheters the patient developed severe radial spasm and access was changed to femoral.
A 5 French JR4 guide was used to engage the RCA. Stent delivery was challenging, but eventually succeeded after deeply intubating the guide catheter almost all the way to the lesion. The stent was underexpanded at 12 atm, but fully expanded after postdilation at 20 atm.
Treating the LAD lesions was challenging due to poor antegrade flow during attempts to place stents. This was overcome by withdrawing the stent into the guide catheter, injecting contrast and then advancing the stent.
The proximal circumflex was stented. The patient had a distal left main trifurcation. Provisional stenting was performed in the distal left main by deploying a stent from the left main into the LAD. Following POT, the circumflex and ramus were assessed with a pressure wire: dPR was 0.98 and 0.91, respectively, hence a decision was made to not perform additional stenting.
Final angiogram after guidewire removal showed a filling defect in the proximal LAD stent. ACT was 280 and the patient was given 600 mg of clopidogrel at the beginning of the case. Eptifibatide was administered. Rewiring was challenging due to the recently placed left main stent, but was eventually achieved using a reversed (“hairpin”) guidewire. IVUS confirmed a filling defect, likely thrombus, that resolved after Penumbra thrombectomy. There was deformation of the left main stent that was treated with implantation of another ostial stent and postdilation with an Ostial Flash balloon, with a nice final result.

[@matheuscsmed]

Thank you, Matheus Silva

[@tom11298]

great because so many teaching tipps and many tools utilized to get this perfect result.

[@TheNEF11]

Really nice job! Thank you!

[@dr.ahmedsaid]

great

[@user-su4he3ju7t]

Thank You very much for interesting and amazing case. Do You open the stent cells from left main to intermediate and from left main to LCx by using kissing or trissing method? Do we need this when we use thin strut DES? In my opinion - yes, but if it possible, can You share with your thinks about that? Take care of yourself, colleagues, Your loved ones.

[@manosbrilakis]

We did not in this case, but would be reasonable to do.

[@nguyenkhanh5956]

Thanks sir so much! Why do you stenting crossover LM to Lcx? Thanks

[@dobryi_chel]

Thank you very much for interest case! Why cardiac surgeons refused to perform CABG? Which contrindications they found?

[@manosbrilakis]

Old age and frailty.

[@wbcjunior]

what is chocolate? in deep catheter intubation does the patient have no pain? how to manage this situation?