Cause of no-reflow not always in coronaries.
Pay attention to guide position and engagement.
Guide cath-induced acute AI.
Hemodynamics compromise, no reflow.
Improved by guide repositioning.
Young male, ACS late presentation.
LCX total thrombotic occlusion.
LAD was mid/distal subtotal occlusion.
RCA CTO with multiple bridge collaterals.
How much to do?
Distal balloon anchor in the same vessel to facilitate stent delivery.
85 y old male, ant STEMI. Total proximal lad occlusion.
Lms calcification and angulation.
Balloon crossed easily, but stent didn't.
Guide support, buddy wire failed.
No side branch anchor available.
Young male. Large ASD.
The posterior superior margin is quite deficient.
RV dysfunction. PASP 90mmhg.
Left to right shunt.
34 mm device. LUPV deployment failed. RUPV deployment.
Device occlusion test for 30min.
No hemodynamics deterioration.
Device released.
Mid-RCA CTO. Short segment.
Carlino.
Pilot 200 crossed easily.
Distal side branch wire perforation.
Vicryl suture embolization via MC into side branch.
Successfully sealed.
Anamolous/ Accessory bronchial artery from LCX or coronary artery to branch pulmonary artery connection.
Lcx and lad were fixed.
My thoughts were accessory bronchial artery from LCX.
Part 2.
What I did.
After heart team discussions.
It was decided to do percutaneous closure so the VSD device was implanted.
There was some residual shunt.
Pt improved dramatically.
Off inotropes on the next day. Stable hemodynamics.
Small calibre vessels in elderly pt is always a challenge especially if it's bifurcation.
Hybrid DES and DCB. DES in MV and DCB in side branches diagonal and OM.
Linear dissection in diagonal and om with timi III flow after DCB.
Decided to accept the results.
Support issues.
Functional CTO.
AL، AR, hockey stick failed to provide adequate support.
MC wasn't able to follow the wire.
The whole assembly disengaged.
JR tried with GCC but unfortunately, 6f GCC hasn't crossed the axillary bend.
Finally, the Side branch anchor did the job.
How to handle this LAD, D1& D2.
One important thing to mention there is a small coronary cameral fistula from the distal lad to LV visible at the end of the cine.
This can create confusion as wire perforation after intervention.
Difficult scenario to deal with.
Young male with severe chest pain.
ST elevation in III, avr, V1 and ST depression in all other leads.
Would like to hear from colleagues, how to handle this.
Part 2
What I did.
Proximal cto was functional crossed easily with pilot 50 & MC. Parked in diagonal. The other one was true cto. Gaia 2 and 3 failed. CP 12 used to puncture the cap. De escalate to gaia 3 but SI. CP 12 used to re enter. Predil, stent, post dil.
Timi III flow.
Poor's man scoring balloon. Critical ostial stenosis RCA.
Predil with 2.5 and 3.0 NC balloons while keeping another wire to create cuts. Good lesion preparation stent expansion.
Contrast modulation for instent CTO.
Morbidly obese pt.
Pci to rca 2018.
Now NSTE ACS.
MC tip injection to identify the cap.
Gaia 3rd to puncture the cap and MC engaged. 1cc contrast injection.
Pilot 200 crossed easily due to contrast-induced microchannels.
Medina 0.0.1. LMS bifurcation.
Difficult anatomical subset.
S/p renal Transplant 4/22
PCI to RCA OSH 12/21.
Now CCS III.
Otimized GDMT still significant symptoms.
What would you do.
AVR in 2000 Starr Edward.
Now severe MS. Pliable valve.
NYHA III-IV.
PTMC
Reverse loop.
Significant sub-valvular disease.
Pulled back carefully to avoid sub-valvular inflation.
28mm Inoue.
Satisfactory final results.
Radial artery perforation and dissection. Guide cath razor effect. Initially, external compression with BP cuff above the systolic pressure. It was still there, then a combination of balloon temponade and external compression did the job.
Acute inf STEMI.
Culprit lcx. Non Culprit LMS, LAD.
Ischemic MR, LVF.
Ppci to lcx. Slow reflow.
Shifted to the ICU. Staged PCI LMS, LAD and ivus guide optimization of lcx stent. During index admission.
A young male precisely 32y old. Ant STEMI. Recurrent VF.
How would you proceed?
1 direct stenting.
2 pre-dil and stenting.
3 aspiration then stenting.
4 aspiration/predial deferred stenting.
If stenting then
1 ostial nailing.
2 cross-over.
Ant STEMI at midnight.
What would you do in such a scenario?
1 Provisional or
2 Upfront 2 stent strategy.
Just curious to know if is there any impact of late working hours on the bifurcation strategy.
What would be your preferred strategy for this LAD/D1.
1 Provisional.
2 upfront 2 stent.
2a DKC or it's variants, micro, mini or nano.
2b culotte or its variant DK culotte.
Another example of contrast modulation.
Mid lad cto.
Ipsilateral septal to septal collaterals.
74y old female. AF.
Cap engaged with MC. 1cc contrast. Pilot 200 crossed easily.
Inf STEMI.
Anomalous RCA.
Failed to canulate from RRA with JR4,AR1, AR2, AL1, MP, XB3, JL3.5.
Switched to RFA.
Was able to locate with AL2 non-selective injection.
84y/f underwent CAG via 6F femoral route. Hemostasis was secured with manual compression.
In CCU, she developed hypotension and massive Ant. Abdominal wall hematoma. Her groin was clean.
Shifted back, did SFA stick, and took the femoral shot.
What do you think what had happened
Surprised to find this much hard, hypertrophic IAS.
48y old male, previous PMBV 19y ago now re stenosis and re PMBV.
IAS stained with contrast and then pushed hard, drilling to puncture and even had to push harder to pass the mullen sheath.
Not sure why it is.
Young male with inf. STEMI
flow restored with wiring without predilation
Now what would be your preferred strategy in this case.
A. Direct stenting.
B. Predilation then stenting.
C. Thrombus aspiration then stenting.
Buddy cath tech for pulmonary balloon valvuloplasty.
Critical PS, severe TR.
Very difficult wire crossing. Glide wire Critical but MP 5, 4 f failed to follow.
Glide cath crossed to stabilize TV & PV.
2nd MP crossed exchanged with stiff wire then Sequential balloon dilation
Jailed balloon tech.
To rescue the side branch.
Tortuous LAD. Extreme angulation at lesion.
2nd septal large size important vessel.
Difficult wiring.
Jailed 2.0 x 10 mm balloon in septal at 4atm while stent deployment.
Finally timi III in septal and LAD.
Follow up of pt post-VSR device closure at 3 weeks.
Now LAD has some flow so decided to fix it.
LV angio mild residual shunt.
Stable device.
RHC
PA 26/12/26
LV 103/36/03.
CO 8L
CI 5L
Qp/Qs 1.5
Asymptomatic.
Decided to continue GDMT.
next FU at 6 weeks.
An interesting case.
PTMC in pt with dextrocardia.
Did this case about 10y ago.
A question from colleagues/ friends.
How many PTMC in dextrocardia have you seen/done.
I did only one and have been waiting for another one.
Pls share your experiences.
Subclavian coronary steal.
Post CABG pt.
Recurrent admissions with HF and syncope.
Occluded svgs.
Left Subclavian CTO.
Retrograde filling via vertebral.
Part 2, what I did.
Depending upon ivus findings decided to fix it from LMS to LCX.
Predil 3.5 NC. Stent 4.0,
POT 5.0, DOT 4.5, KBI 4.5/3.5, Re POT 5.0.
Ivus guided
TVD, cabg refused.
After pre dil somehow wire and guide disengaged. Ostial dissection.
Aw failed. Bailout retrograde wire to engage the true ostium.
Stented to heal the ostial dissection.
Fu no further extension of dissection.
Remained stable.
Asymptomatic at several months FU.
Large ASD secondum.
Deficient aortic rim.
24 mm device.
Descend from LUPV failed to capture the aortic rim and prolapse in RA.
Recaptured.
Clockwise rotation and deployed.
Perfect landing.
Large PDA with severe PHTN.
30 min device occlusion test.
PAP increased from 96 mmHg to 106 mmHg.
AO pressure remained the same at 110/60mmHg.
Sat dropped from 94% to 82%.
PVR 8 wu.
Decided to retrieve the device.
FU of the case.
Started with LCX/ OM stenting.
Did DCB to mid, distal LAD.
After these encouraging results decided to intervene in the RCA as well in the same setting.
AR2, HS, Lima and JR guide used.
TPLP MC, pilot 200, Gaia 2nd wire.
Timi III flow achieved.
Wire manipulation in tortuous LAD.
80y male, ACS.
Tortuous radial and subclavian.
Iliac and aortic tortuousity. Xb failed. JL4. Wire in lcx to stabilize. Difficult wire crossing in proximal lad first crossed in septal balloon dottering then pull and crossed in LAD.
Severe diffuse disease.
Surgical turndown.
Lad total occlusion.
DCB to the mid, distal lad.
Plan to have angiographic FU at 6 weeks and staged PCI to RCA.
Would like to hear from colleagues
These angiographic results are Acceptable or not.
PMBV in 10y old child.
Prevalence of RF/RHD is horrible in our part of world.
Not a one case frequently used to do it in 8, 10, 12 y old children.
Must be eradicated by.
Extensive primary prevention programme.
Training and education of GPs.
Awareness program.
Media conpaign.
CTO mid rca.
Initially looks ambiguous proximal cap.
Dual injection short cto with intraplaque channel.
Crossed easily with fielder wire.
Final good results.
F/U of the case.
PJ wire used with MC. wire manipulation was done Multiple times due to multiple channels. Fine found the right channel. Distal true lumen confirmed with pressure from MC and tip injection.
56y old female. 39kg wt.
SOB fc III, IV symptoms.
Large ASD secondum. 29x25x24.
Deficient aortic rim.
Sufficient other rims.
30 mm amplantzer device deployed.