CASE 01

Overview

Successful revascularization of difficult chronic total occlusion in left anterior descending (LAD) artery in an elderly patient.


Patient History

  • 71 years old diabetic and hypertensive gentleman admitted under Dr. Sunip Banerjee with a complaint of chest pain during mild work.
  • His echocardiogram revealed mild dysfunction of left ventricle as some area of heart is not functioning properly.
  • He was immediately advised for coronary angiogram for diagnostic purpose.
c01-cag1 c01-cag2 c01-cag3

Diagnostic CAG

  • His coronary angiogram showed double vessel disease in LAD and Left Circumflex (LCx) artery ( Fig 3) including very difficult chronic total occlusion in proxy-mid region of LAD ( Fig. 1 & 2).
  • Revascularization of diseased arteries was planned through percutaneous coronary intervention (PCI) with implantation of stents in diseased area of LAD and LCx.
  • The most challenging part of the process was to cross the chronic total occlusion area of LAD as lesion was old one and significance of artery to supply the blood in left ventricle. Previous attempt was made to cross the lesion by other operator which was in vain. Dr. Banerjee took the challenge and crossed the lesion with modern hardware after hours of skillful effort (Fig 4) and ultimately stented the lesion part with great success ( Fig 5) as stent was positioned accurately in the intimal layer of the artery.
  • Subsequently, another stent was implanted in the diseased area of LCx (Fig 6).
  • Post procedure picture showed excellent flow of blood through both the arteries (LAD & LCx) (Fig 7).
c01-process1 c01-process2 c01-process3 c01-process4

Challenges to overcome during procedure by Dr. Banerjee

  • Patient with less heart function.
  • Patient was elderly. As the procedure could be time consuming there was a great risk of deterioration of patient’s hemodynamic condition on table.
  • To cross this CTO lesion was a great challenge which always demands great amount of experience, patience and knowledge of using modern hardware.

Dr. Banerjee was inspired from the great quote by Bruce Wayne "Everything’s impossible until somebody does it."

CASE 02

Overview

Bifurcation Stenting with double Kissing double crush technique.


Patient History

  • 46 yrs old male presented with acute chest pain
  • ECG revealed Anterior Wall STEMI ( Deep T inv V1-V6, T inv I, avL, T inv II, III, avF)
  • Echo revealed RWMA in LAD territory and moderate LV dysfunction (LVEF: 42%)

Diagnostic CAG

diagnostic CAG 1 diagnostic CAG 2 diagnostic CAG 3

Conclusion & Teaching point

  • We adopted the DK Crush (double kissing-double crush) technique in a view that this would give us better outcome in long-term basis.
  • This technique has several advantages over conventional kissing balloon dilation in respect to bigger minimum lumen diameter and lesser residual stenosis at the ostial side branch.
  • Other than that the outcome of this technique compared to the classic Crush strategy seems to be superior in terms of repeat intervention rates.

CASE 03

Overview

Managing Large Abdominal Aorta Aneurysm by Endovascular Stenting.


Patient History

  • 58 yrs male presented with severe back pain.
  • Hypertensive
  • Diabetic (type 2)
  • Chronic kidney disease
  • S/P CABG 4 months back
  • ECG revealed - Inferior wall MI and Sinus tachycardia
  • Echo revealed - Generalized wall hypokinesia, LVEF: 50%, Mild MR and Gr II DD+
diagnostics1 diagnostics2

Conclusion & Teaching point

Big aortic aneurysm can be managed by appropriate endovascular Stenting strategy.

final

CASE 04

Overview

RCA Chronic total occlusion crossed by parallel wire technique.


Patient History

  • 65 years old male presented with shortness of breath Class II
  • Patient was hypertensive
  • ECG revealed - T inversion III and ST depression in II, III, aVF
  • Echo revealed - Regional wall motion abnormality in RCA region and LVEF: 51%
  • Coronary angiogram done outside showed multi vessel disease
diagnostics1 diagnostics2

Conclusion

Parallel wire technique was used to cross the difficult CTO lesion.

final1 final2

CASE 05

Overview

Left Main Stenting through radial approach.


Patient History

  • 58 years old female presented with angina on exertion class II
  • Patient with Hypertension & hypothyroidism
  • ECG revealed - Sinus rhythm and Antero-Septal Ischemia
  • Echo revealed - Concentric Left ventricular hypertrophy, No wall motion abnormality and EF: 68%

Diagnostic CAG

diagnostics1 diagnostics2

Conclusion

Left Main lesion Stented in radial approach.

final1 final2

CASE 06

Overview and Patient History

  • 64 yrs old male presented with acute chest pain
  • S/P CABG (2005) – LIMA->LAD, D2; Radial->OM1
  • STEMI (ST↑ II, III, aVF), RBBB T inversion in V1-V5
  • Echo: Conc. LVH, LVEF-50%
  • Advised: CAG
diagnostics1 diagnostics2

After doing Angioplasty

result

CASE 07

Overview and Patient History

  • 51 yrs old male presented with angina on exertion ( Class II)
  • TMT positive
  • He was hypertensive & diabetic
  • ECG: Non-specific ST-T changes
  • Echo: Conc. LVH, NO RWMA, EF 60%
  • Advised for CAG
diagnostics1 diagnostics2

After doing Angioplasty

afterangio1 afterangio2

Conclusion

  • Challenges of treating CTO in BVS
  • Sizing of BVS
  • Placement in the ostium (where to keep the mark?)
  • In absence of OCT how to precisely position?

CASE 08

Overview and Patient History

  • 60 yrs male presented with NSTEMI
  • He was dyslipidemic
  • ECG: Left axis, No significant ST-T elevation changes
  • Echo: No RWMA, LVEF- 65%
  • Advised for CAG
diagnostics

After doing Angioplasty

afterangio1 afterangio2

Conclusion

  • This technique has several advantages over conventional kissing balloon dilation in respect to bigger minimum lumen diameter and lesser residual stenosis at the ostial side branch
  • Other than that the outcome of this technique compared to the classic Crush strategy seems to be superior in terms of repeat intervention rates
  • DK Crush (double kissing-double crush) allows most complete coverage of carina

CASE 09

Overview and Patient History

  • 64 yrs old male presented with chest pain on exertion
  • S/P CABG ( 1998): SVG-> LAD, PDA
  • He was hypertensive
  • ECG: ST↓ + T inversion I, V2-V5
  • Echo: RWMA+, LVEF-48%
  • Advised: CAG
diagnostics1 diagnostics2

After doing Angioplasty

afterangio

Conclusion

With distal protection device, the new generation cover stent may be a more easily deliverable and cost effective option.


CASE 10

Overview and Patient History

  • 65 yrs of post MI (thrombolyzed) female presented with angina on exertion (Class III) for last 3 months
  • She was hypertensive & diabetic (Type 2)
  • ECG: q in III & aVF. ST↓ V4-V5
  • Echo: RWMA+ in RCA region, LVEF-55%
  • Advised: CAG
diagnostics1 diagnostics2

After doing Angioplasty

afterangio

Conclusion

  • Wire crossed but not the balloon
  • Deep intubation of guide (need to be co-axial. Still ostium.)
  • TORNUS (Angulations & Cost)
  • Anchor Balloon

Contact Us

For Appointment

Call : Ms. Sumana
+91 9903203724

For MI, ECG Picture

Send on Whatsapp
Number : +91 9836206342

For Online Appointment

www.drsunip.com
Kindly take Appointments 1 Month in advance.