European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Clinical Case Author: Julien Adjedj, MD, Institut Arnault Tzanck, France 68 YEAR OLD MALE PATIENT HIV Previous inferior MI in 2006 Left main equivalent PCI in 2006 Cypher 3.5 x 18 mm Dyspnea NYHA II LVEF 40% inferior akinesia
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Ivus guided lad cto lm bifurcation stenting Author: Dr Joby K Thomas, MD, DM, Caritas Hospital Kerala, India SUMMARY Patient underwent CABG and mitral valve repair in 2014 at a different hospital Had effort angina which revealed occluded LIMA and both SVGs(2017) They attempted PTCA , did RCA and ‘ramus ‘ stenting LAD was ostial CTO , which they could not succeed in doing Patient still has angina Check angio showed patent stents in RCA and ‘ramus’ That converted a 0,1,1 LM distal bifurcation to 0,1,0 But LAD ostial CTO with no stump
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS LM Bifurcation Complication or 'should we have touched it?' LM DEB PCI on high risk bleeding…
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Complete Revascularization with ROTA Author: Tanveer Rab, MD, Emory University School of Medicine Atlanta, Georgia, USA OUTCOMES PROCEDURAL Contrast: 300 cc Exposure: 4.5 Gy LVEDP: 22 LFA preclosed; post closure completed after removal of 14 Fr Cook sheath RFA access sheath perclosed IN HOSPITAL Hemodialysis same night post procedure and on 3rd day post procedure Transfusion of 1 unit of blood Felt much improved and ambulant Home, post procedure day 4 AT ONE YEAR Came off hemodialysis Creatinine stabilized at 3.0 LVEF improved to 45 % MR improved (mild) Alive and well at 1 year
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASES SESSION - TIPS & TRICKS Difficult SB Access with size discrepancy to MB Author: Khaled Al Shaibi, MD, King Fahd Armed Forces Hospital, Saudi Arabia CASE HISTORY 80 year old female Hypertension Unstable angina ECHO:-EF = 50% no significant valve pathology Coronary angiography:- Distal leI main plus three vessel disease (SYNTAX score = 36 ) Turned down by surgeons due to fraility
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASES SESSIONS - TIPS & TRICKS Impella and LM Stenting with PS and POT: Keep it Simple Author: Johan Bennett, MD, PhD, University Hospitals Leuven, The Netherlands CLINICAL CASE 64 year old male Diabetes Mellitus, ex-smoker Prostrate cancer with bone mets (stable on hormone therapy) Presented with ACS and pulmonary oedema SUMMARY Protected High risk PCI of LM bifurcation Impella CP supported Ventriculo-arterial uncoupling Provisional LM stenting Intracoronary imaging to ensure optimal result
A case of huge coronary perforation during insertion of a long stent in severe calcified bifurcation lesion Author: Yoshinobu Murasato, MD, PhD, Kyushu Medical Center, Japan Take home messages: • A long stent insertion in the calcified bifurcation lesion led to stack of the stent and S-figure flection which resulted in huge coronary perforation. • The situation that 1/3 of the stent remained in the guiding catheter might induce strong push-ability to make S-figure flection in the coronary artery. • When we feel hard resistance during insertion of a long stent, we should consider another option as the following earlier. Biplane fluoroscopy for detailed observation of the stent stack Buddy wire to change the wire bias Guide extension catheter to enhance back-up force and prevent the stent flection inside the coronary artery.
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain COMPLICATION CASES Protective Strategy for Side Branch in Complex Bifurcation Lesions During PCI Author: Man Wang, MD, Fuwai Hospital, China SUMMARY Provisional stenting strategy is preferred in non-left main BIF Jailed balloon technique is effective for keeping side branch open with high success rate of rewiring Easy withdrawal of jailed wire and balloon in SB Rewiring and final KBI is not necessary when SB TIMI flow is 3
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain COMPLICATION CASES Unexpected Global Dissection Author: Jorge Palazuelos Molinero, MD, PhD, Prof A. CASE REPORT. INDEX ANGIOGRAPHY Female, 70 yo. HTN. Referred to cath lab for chest pain with posi1ve exercise test CONCLUSION Keep calm Patient care Step by step approach: 1. expert operator supervision 2. Adequate material Be aware of deep intuba1on, extensor catheters and mechanical contrast injections
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain COMPLICATION CASES Devil wears Prada: LM stenting, problem of ostium coverage Author: Himanshu Gupta, MD, DM, PGI Chandigarh, India CLINICAL PROFILE 50 Years Male HTN, No DM, Former Smoker 1 episode of Syncope 10 days back ECG – Normal with no baseline ST changes Evaluated at OSH and found to have CAD LVEF- Normal LV function with no baseline RWMA or valve disease PROBLEM After FKB the LAD wire position was lost as the balloon got stuck on the wire LAD rewired with another wire Position of the fresh LAD wire in doubt?? LCX wire is good–Maybe, we have done a FKB already LEARNING POINTS Short LM and abnormal take off can cause problems FKB not mandatory in provisional SB strategy If u KISS – It should be good and safe Rewiring always after POT – But be careful Use dual lumen catheter to wire SB if in doubt Never do POT on SB wire Use Guide extension to prevent LSD Angiographic follow up if possible