High risk left main PCI supported by IABP

Case summary

-Age: 77 year old
-Gender: male
-NIDDM; Hypertension; Dyslipidaemia
-Previous pacemaker implantation
-Known IHD:
-1980: inferior MI (no details)
-2014:   preserved LV function with   infero-basal hypokinesis
-Known Carotid Artery Disease:
-70% right internal carotid
-100% left internal carotid
-Pulmonary oedema with uncontrolled BP and mild troponin rise
-ECHO: LVEF 40%, inferior akinesis
-LM: moderate stenosis distally (MLA 7.64 mm2, FFR 0.87)
-LAD: severe stenosis LAD-D1 bifurcation (MLA 2.54 mm2), FFR catheter could not cros
-Cx: critical 90% calcified stenosis proximally
-RCA: CTO proximally with septal collaterals from LAD
-SYNTAX score: 32
-Turned down for surgery

Strategy

ACCESSES:

-RFA: XB 3.5 7Fr
-LFA: IABP (LVEF 40%, LM disease with RCA CTO à last remaining vessel)

APPROACH:

-Predilatation of Cx
-Rotational atherectomy of LM-LAD and LM-Cx (1.5 mm burr)
-Predilatation of LM-LAD and LM-Cx with NC balloons +/- scoring balloon
-IVUS
-Stenting (two-stent strategy: DK crush vs culotte)
-Post-dilatation with NC balloons (POT, kissing)
-IVUS
-Evaluation of CTO PCI on RCA at a later stage

Protocol: OptiRAY (Ioversol)