Introduction
This case study elaborates on a complex percutaneous coronary intervention (PCI) performed on a patient with a history of coronary artery bypass grafting (CABG). The patient presented with significant stenoses in both native coronary arteries and bypass grafts, necessitating a nuanced and strategic approach to intervention.
Clinical Presentation
A patient with previous CABG surgery presented with symptoms indicative of recurrent ischemia. Diagnostic procedures revealed multiple critical lesions:
- A tight stenosis in the LIMA graft to the LAD.
- Critical ostial and proximal stenosis in the RCA.
- Substantial stenosis from the native left main to LCX and OM2.
Objective
The objective was to alleviate symptoms and improve myocardial perfusion by addressing the stenoses using PCI, which involves multiple sites including a graft and native coronary arteries.
Interventional Strategy and Procedure
-
LIMA to LAD:
- Diagnosis: Initial angiography highlighted severe stenosis in the LIMA graft leading to the LAD, critical for left ventricular function.
- Interventional Approach:
- Wiring: A Whisper wire was used to cross the lesion due to its flexibility and support.
- Predilatation: Balloon predilatation was performed to prepare the lesion for stenting.
- Complication Management: Post-initial stent placement, LIMA spasm led to no flow, which was relieved with intracoronary NTG and Nicorandil, and careful post-dilation.
- Outcome: The procedure concluded with successful restoration of flow as observed in the final angiogram, indicating a significant improvement in artery patency.
-
RCA Intervention:
- Diagnosis: The RCA showed critical ostial and proximal stenosis with compromised flow.
- Interventional Approach:
- Lesion Crossing: A Fielder XT wire supported by a balloon was used to cross the critically stenosed area.
- Predilatation: This step was crucial to facilitate the stent placement.
- Stent Placement: A stent was carefully placed to cover the ostium, ensuring full coverage of the lesion.
- Stent Adjustment: Post-placement, the stent required inflation, and a guide was used inside the stent for adjustment to avoid proximal distortion.
- Final Touches: An ostial flair was managed with a 4mm NC balloon to ensure perfect stent apposition.
- Outcome: The RCA’s flow was fully restored as evidenced by the final angiogram, demonstrating successful intervention.
-
Native LM to LCX:
- Diagnosis: Significant stenosis was noted extending from the native left main to the LCX and OM2.
- Interventional Approach:
- Predilatation: The stiff lesions were prepared with balloon dilation.
- Stent Placement: Strategic placement of stents was carried out to ensure the lesion was adequately covered.
- Stent Dilatation: Post-placement, stent dilatation was performed to ensure optimal stent expansion and vessel support.
- Outcome: The final angiogram revealed a well-expanded stent with excellent blood flow, marking the procedural success.
Discussion
This intervention highlights the complexities and strategic considerations involved in managing post-CABG patients with recurrent coronary artery disease. The use of specialized equipment and advanced techniques was pivotal in achieving successful outcomes across multiple challenging lesions.
Conclusion
The successful management of this case through PCI demonstrates the potential for interventional cardiology to effectively treat complex cases in patients with previous CABG. This approach not only alleviates symptoms but also significantly improves the quality of life by enhancing myocardial perfusion. This case provides valuable insights and reinforces the importance of a tailored approach in the treatment of complex coronary artery disease.