1. Meruzhan Saghatelyan, MD, Interventional cardiologist
Nork Marash Medical Center, Yerevan, Armenia

2. CTO recanalization and unprotected LMCA angioplasty in post CABG patient with failed grafts

3. Patient Data
68 years old male was admitted for clinical evaluation because of class III stable angina pectoris.
Cardiovascular risk factors: hypertension and hyperlipidemia, ex-smoker.
Past medical history:
In 2011 the patient had been hospitalized with acute coronary syndrome in another country.
Coronary angiography revealed proximal LCX occlusion and ostial LAD disease. After failed PCI attempt, he underwent CABG surgery with arterial grafts: LAD artery had been grafted by LIMA and OM branch by radial arterial grafts. The patient gradually became more and more symptomatic during the last year.

4. Clinical Data The patient had no significant comorbidities.
Normal sinus rhythm without ECG abnormalities.
Mild to moderate LV hypertrophy and preserved LV contractility without regional wall motion impairment on transthoracic echocardiography.
Normal renal function.
Laboratory tests were normal.

5. Coronary angiography Coronary circulation was of co-dominant type.
LAD artery had diffuse calcified disease with ostial tight subtotal lesion extending just from distal LM bifurcation to the mid part /Medina 0,1,0 lesion of LM bifurcation/. LIMA graft was nonfunctioning.
The ostium of the LCX artery was intact but there was CTO lesion of proximal to mid circumflex with blunt stump, small side branch at the occlusion, some calcification and bifurcation at the distal cap. The occlusion length was less than 20mm. Distal artery was filled by ipsilateral atrial channels and from right PL collaterals. RA graft to OM branch was nonfunctioning.
The RCA was small artery with intermediate lesion in mid part.

10. Atrial channel

11. Right PL channel

12. Nonfunctioning LIMA graft

13. SYNTAX score was 38 /RCA was not included/.
The logistic Euroscore index was 3.
The patient denied the option of repeat CABG surgery without any discussion.
PCI procedure was planned that included two complex procedures in order to achieve complete revascularization:
Proximal to mid LCX CTO recanalization with distal bifurcation;
Unprotected LM intervention.
We decided to stage the procedures and to start with CTO PCI.

14. CTO PCI procedure Femoral approach with 7F XB 3.5SH guide catheter.
5F sheath was placed in contralateral groin in case the contralateral injection is needed.
We started with Gaia 1st wire and Finecross microcatheter. That wire could not be advanced beyond the proximal fibrous cap.
The proximal cap was penetrated with Conquest Pro 12 guidewire. We tried to advance the Conquest Pro 12 wire to the distal true lumen but the wire went subintimally at the distal cap. Then we exchanged the wire again with Gaia 1st in order to have better torque control.

15. Gaia I could not be advanced into the CTO body

16. Conquest pro 12 with Finecross

17. Conquest pro 12 advanced into the CTO but went subintimally at the distal cap

18. Conquest pro 12 advanced into the CTO but went subintimally at the distal cap

19. Conquest pro 12 advanced into the CTO but went subintimally at the distal cap

20. Back with Gaia I and Finecross

21. Gaia I went through the same subintimal path
Gaia I went through the same subintimal path. Parallel wiring with Miracle 6 was successful. After the passage, Miracle 6 was exchanged with floppy wire via microcatheter.

22. Miracle 6 exchanged to floppy wire via Finecross

23. Predilataton of the CTO lesion was made with 2. 0mm balloon
Predilataton of the CTO lesion was made with 2.0mm balloon. After the predilataion and restoration of antegrade flow, mid LCX was wired. One NOBORI 2.75x28mm DES was deployed in proximal to mid LCX with good result.

24. After predilatation with 2.0 balloon

25. Mid LCx is wired

26. After stenting of LCx with Nobori 2.75x28 DES

27. The OM branch was rewired and kissing balloon inflation was made in LCX and OM arteries. The result in OM branch was unsatisfactory, the artery was dissected, and we decided to implant the second stent in it and to reconstruct the bifurcation. A 2.5x33mm DES was deployed in OM branch using TAP technique, and final kissing inflation was made with good final result in both branches.

28. Kissing balloon inflation in LCx and OM branch

29. Dissection of OM after kissing

30. Stenting of OM with 2.5x33 DES using TAP technique

31. Final kissing inflation

32. Final result

33. LM and proximal LAD PCI procedure
Femoral approach with 7F XB 3.5 guide catheter
LAD, 1st Diagonal and LCX arteries were wired with floppy guidewires.
Predilatation was performed starting from mid part of LM to the mid part of LAD using 3mm non-compliant balloon.
A 3.0x28mm XIENCE DES was deployed in mid LAD.

34. LAD, 1st Diagonal and LCX arteries were wired

35. Predilatation with 3mm non compliant balloon

36. Predilatation of mid LAD

38. Predilatation of mid LAD

39. Predilatation from LM to proximal LAD

40. After the predilatation of ostial LAD

41. 3.0x28mm XIENCE PRIME DES in mid LAD

42. Ostial and proximal LAD lesion

43. We decided to treat 0,1,0 type LM bifurcation lesion with one stent technique.
A 4.0x33mm XIENCE PRIME DES was deployed from proximal LM to mid LAD overlapping the first stent and across the LCX artrey.
The result in LM and LAD was good, but the ostium of LCX was pinched. LCX was rewired and kissing balloon inflation was made using 4.0mm non-compliant balloon in LM to LAD and 3.0 mm non-compliant balloon in LM to LCX with good final result in both arteries.

44. 4.0x33mm XIENCE PRIME DES in prox LM to LAD

45. Stent deployement

46. LCX ostium was pinched after LM to LAD stent ing

47. Kissing balloon inflation in LM to LAD and LM to LCX

48. Final result

49. Final result

50. Final result

51. Final result

52. Final result

53. Summary
Surgery remains the standard of care in patients with multivessel disease including LM with high SYNTAX score.
However the surgery is denied frequently by such patients in real life, or is not acceptable by any reason.
In these patients, thoroughly planned PCI procedure can be safe and successful alternative to the surgery to achieve complete revascularization.
In cases when two complex procedures are to be performed in the same patient, staging the procedures is more reasonable and safe.

54. Thank You