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This didactic procedure concerns a patient adressed from neighboring hospital for acute anterior STEMI within the first hour. The coronary angiography has shown distal left main stenosis and Proximal LAD thrombotic occlusion.
This procedure show how to deal wih crossing difficulties during primary PCI as well as management of "no reflow phenomenon".

Educational objectives

  • How to treat patients with acute STEMI.
  • Some acute thrombotic lesions may be challenging to cross.
  • How to use dedicated CTO devices during non-CTO PCI.
  • How to use thrombo-aspiration catheter to deliver adenosine distally.
  • How to treat "no reflow phenomenon" during primary PCI.
  • IVUS guidance to control stent deployment & Left main stenting during primary PCI.

Step-by-Step procedure 

  • The patient has experienced repetitive cardiac arrest due to ventricular fibrillation, so he was intubated & admitted to cath-lab.
  • Right radial 6F access.
  • First coronary angiography: right system first.
  • EBU 3.5 6F guiding catheter used for the left system.
  • Left system angiography showed distal Left main significant lesion & proximal LAD thrombotic occlusion.
  • The Sion black guidewire alone has failed to cross the lesion.
  • Conventional balloon support (Rapid Exchange) has also failed to facilitate crossing the lesion.
  • Finally the lesion was crossed succesfully with Sion black guidewire & CTO dedicated microcatheter (Turnpike LP: Teleflex) support.
  • Predilatation with 2.0x20mm balloon has been performed.
  • First stent implantation: Xience Sierra 3.0x28mm (Abbott) in the proximal-Mid LAD inflated at 12ATM.
  • The angiographic control revealed LAD "non reflow ".
  • Thrombo-aspiration cathter Export 6F (Medtronic) was used to deliver distally repetitive Adenosine Bolus.
  • The angiographic control with Tip injection through the Export catheter showed sgnificant flow improvement.
  • Second short stent  Xience Sierra  2.75x8mm(Abbott)  was implanted to cover distal edge dissection.
  • IVUS was used to control LAD stents deployment & assessment of the distal Left main stenosis. 
  • Third Xience Sierra (abbott) 4.0x28mm was implanted on the left main to the Proximal LAD with some plaque shift to the Left circumflexe artery.
  • POT was performed with a 5.0x8mm balloon, the patient has experienced again a Ventricular fibrillation during balloon infation.
  • The final angiographic & hemodynamic results were satisfactory.

Protocol

  • Contrast medium: Optiray 350 (Guerbet): 179ml.
  • Prcedural time: 60min.
  • Exposure time: 19min.
  • Exposure: 2399mGy.

Biobliography

Shooting date : 2018-07-16
Last update : 2021-05-11

OptiRAY® / Guerbet

Optiray® contrast agent is lower osmolar, lower viscosity and nonionic.

XIENCE Sierra / Abbott

Everolimus Eluting Coronary Stent System

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  • Mahmood H. What about the origin of circumflex need any thing to be done for it ?

    • Chris Z. the origin of the Circumflex was disease free on IVUS and that is one of the reasons e did the IVUS. it had a bit of corinal shift but no need to do anything. did a POT. Good result

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  • Hesham M. Why did you stent the left Main ? what was the cross sectional area of left main ?

    • Chris Z. stented the left main as the disease extended into the left main and as the lesion was osteal with disease in the left main better long term result. high probability of missing the osteun with osteal stent as well. the left main was assessed by ivus and the stent was post dilated to the appropriate size.

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  • Abdulhakim D. Do you need relook after stabilization?

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    • Hasan F. Fine

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      • Maria B. No comment

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        • Rocco Edoardo S. Well done. Why don’t performe final kissing balloon LM-CX, but only POT?

          • Ahmed B. This comment has been moderated

          • Ahmed B. I think that it was because the instability of the patient, the complicated procedure, I think the operator tried to be efficacious and objectively the result was satisfactory with provisional in this context

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        • Osman . Thank you

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          • bassem J. youforget tomention the stent xiencesierra 4x28mmput inthLMC

            • Ahmed B. @bassem J i think it was mentionned in the description !!!

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          • Osman . Thank you

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            • Mohamed A. Well done

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              • lotfi R. hello i cant watch movie
                what format or app should i use
                thanks

                • Ahmed B. Hello , Do you use phone or computer?

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              • Pecheux M. What about thé diagonal?

                • Ahmed B. I think operators just accepted the result in the context of unstable patient...

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              • mike P. utter cowboy
                balloon support in fresh lesion threatens mayhem
                who is this guy ?

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                • Segal D. well done!

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                  • Tekten T. Ok

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                    • Tekten T. Good job

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                      • Tekten T.

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                        • ahmed B. Nice case, But I have a question regarding the ballon inflation in the ostial lesion with the wired not secured distally. I think if a dissection could have happened it would have turned into disaster with the wire hanging infront of the lesion

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