Case 45: PCI Manual - When things don't go well

An elderly woman presented with NSTEMI due to a culprit lesion in the mid LAD immediately proximal to the bifurcation of a large diagonal branch. Attempts for wiring through the lesion resulted in acute vessel closure, resulting in hypotension and cardiac arrest. Patient was resuscitated and an IABP was placed. She also had aortocoronary dissection treated with left main stenting. The LAD was rewired and antegrade flow was restored. After stenting a perforation occurred at the distal edge of the stent. Delivery of a Graftmaster covered stent was extremely challenging due to calcification and diffuse disease, but eventually succeeded after changing to femoral access and inserting an 8 French Guideliner. The covered stent, however, likely subsequently occluded the large diagonal branch. The patient had a post-procedural myocardial infarction and subsquently died.

[@mustafaoguzvarol6133]

It requires great courage to share not only good but also bad results..I appreciate your style.

[@hectorjaviermartinez5148]

Dr. Brilakis I congratulate you for the heroic nature of this extremely complex PCI. As a high risk operator myself I understand the frustration that goes in the cath lab when we have to take on this kind of procedure. Thanks for sharing!!!! I am humbled by your presentation of this case. It requires a courageous physician to share his or her complications but I admire your purpose to provide a higher learning opportunity. I will continue to support your effort and will continue to enjoy learning from your techniques.

[@alecandreva]

That is one of the top 3 cases of the library. Thanks for sharing!

[@Stentz1]

I am a practicing interventional cardiologist in Florida. Fan and subscriber of your channel. We have all been in these situations where things take an unexpected course . Just the nature of the beast. It was a high risk case to start with and nobody expected a simple fix . Kudos for sharing . As the equipment becomes smaller and more deliverable we tend to forget that a crashing patient is always a few seconds away. Keep the videos coming!

[@TheNEF11]

thank you very much for presenting the case. On the first shot one could imagine that the case would be very very challenging. The papyrus is a alternative but as one of the earlier comments said a little bit les tight on the belloon, so mother-child catheter would be the key

[@matheuscsmed]

Thank you, Matheus Silva

[@revolution425]

Thank you for sharing. That was a tough case with all the elements working against you. I learned many things from this. Please continue to share future work with us

[@grjvlk]

Thank you for sharing this case! I hope you will not need a pk-papyrus for a long time.... but if you do, a word of caution: they do tend to sit rather loosely on their balloons, so guideliner is quite obligatory. Or have a micro-snare nearby...

[@sofianeghebghoub2062]

Great case thank you for sharing

[@ashikmd677]

very informative and useful for an interventionalist thank u

[@user-er3kx8qr3g]

very thanks for your sharing. Big agree with MUSTAFA OGUZ VAROL.

[@doctorcardio3886]

Did you consider medical management at any point of time especially considering her age?

[@itsnerdbehaviour21]

Thanks for the great case...makes me wonder if an off pump lima to lad would have been a safer option in this patient

[@manosbrilakis]

Retrospectively yes - but that assumes that the surgeon agrees to operate, which was not the case here.

[@itsnerdbehaviour21]

@@manosbrilakisYes of course...retrospectively only. Thanks for the learning points!

[@schiefix]

84, frail, severe COPD, severe calcific 3VD. OMT in my books. Why? Watch the video.

[@aq4019]

Sir, as always hats off to your effort and professionalism! Did you do this operation from the start until the end? According to ur info,the duration was 6 hours. How much time did u loose for inflating diagonal branch? What was the amount of blood in pericardium? Thank you and good luck in your tough work!

[@manosbrilakis]

Yes I did. Hard to estimate exact times but probably 3-4 minutes.

[@vector222]

Why no impella in this case?

[@marcuslee2139]

Great case. In hindsight, would provisional stenting of the LAD and leaving the diagonal alone be an alternative strategy? Get her off the table and if she does ok, leave it. If she deteriorates, then your hand is forced.

[@manosbrilakis]

Provisional stenting is what we did. We did not stent the diagonal.

[@DanPascut]

I agree that the LAD was the culprit. But if the patient is stable , would you consider trying to open the CTO first to give yourself better conditions for the LAD lesion ?

[@manosbrilakis]

Prophylactic CTO PCI in an 84-year-old with ACS and clear culprit would probably not be the right course of action (CTO PCI carries risks in itself). But agree that if the RCA was opened to risk of intervening in the LAD would be lower.