Case 22: PCI Manual - Acute closure

A patient presented with unstable angina. Coronary angiography showed severe distal RCA lesion with heavy calcification and intermediate lesions in the LAD and circumflex. Both lesions were significant with both resting (Pd/Pa) and hyperemic (adenosine FFR) indices. Patient was referred for CABG but declined and returned for PCI of the RCA. Wiring attempts resulted in acute RCA closure, but patient remained hemodynamically stable and angina-free. Retrograde crossing attempts were successful in advancing a wire through a septal collateral, but a Caravel microcatheter could not cross and the retrograde wire position was lost. Repeat antegrade attempts resulted in successful crossing of both PDA and PLV. Because of dissection in both branches, a two-stent DK crush strategy was selected. DK crush was challenging because of difficulties recrossing the stent with balloons and wires, but was eventually successful with TIMI 3 flow in both branches.

[AmeerMusa]

Thank you for sharing this great case Dr. Brilakis. Regarding the physiological assessment of the LAD, could this value be falsely low due to the LAD also supplying collateral circulation to the nearly CTO RCA? It would be interesting to repeat the assessment after opening the RCA to see the difference.