Case Summary

A 66 year old gentleman, non-smoker, with diabetes, hypertension and hypercholesterolemia presented with unstable angina. He had past history of triple vessel disease with coronary stenting done in another hospital in 1995, the details of which was unknown. Coronary angiogram revealed severe mid LAD in stent restenosis (ISR), severe proximal LCX in stent restenosis and distal to stent another subtotal occlusion, whereas proximal RCA was near totally occluded (Movie 1, Movie 2, Movie 3). The mid LAD lesion was first treated in last session smoothly but subsequent attempts to open LCX ISR failed despite repeated use of high pressure noncompliant balloons. IVUS showed circumferential calcium and under-expansion of previous stent (Movie 4, Figure 1) despite it failed to advance distally.

Procedure

LCX was reattempted 3 months later (Movie 5, Movie 6).

6F EBU 3.5 guide was used.  LCX to OM was wired with Fielder XT supported with Finecross microcatheter (Movie 7). The undilatable pLCX segment was again POBA with multiple high pressure noncompliant balloons including Angioscult 2.5x15mm  (26atm), OPN NC 2.5x10 (40atm), NC Emerge 3x12mm (26atm), OPN NC 3x10mm (40atm), eventually the distal segment of the old stent opened up but not the proximal stent part (Movie 8).  Therefore, it was decided for rotablation with 1.5 burr then upsize to 1.75burr. However, it still failed to dilate the lesion. Afterwards, we retried POBA with OPN NC 3x10mm and the lesion finally yielded at high pressure (37.5atm) which was confirmed with IVUS (Movie 9). In view of small dLCX, it was decided to stent into OM with Ultimaster 2.5x28m overlapped with Ultimaster 3x33mm proximally. Subsequent angiographic result was excellent (Movie 10, Movie 11).