Clinical Presentation

Coronary Angiography Report

Risk Factors

• Hypertension
• Type 2 diabetes mellitus

ECG

• Sinus Rhythm
• T wave inversion V1 – V4
• Good LV systolic function
• AO/LVEDP/PCWP: 160/80/107

Approach – Right femoral

Catheters

• 5F JL
• JR 3.5

Contrast Media

• Contrast – Omnipaque
• Quantity – 50 ml

Flurotime: 7.29 Min

• Left Main: Distal LMCA has 80 % stenosis
• Ostial LAD has 90% stenosis. Mid LAD has total occlusion

Ramus Intermedius: NA

• LCX/ OM: Dominant Ostial LCX has 90% stenosis
• Non dominant. Diffusely diseased

LIMA/RIMA

• LIMA-LAD-> Absent
• SVG-LCX-> Patent
• SVG-LAD-> Discrete 90% stenosis in proximal half. Distally slow flow noted.

LV Angiogram

– NA

Renal/Angio/Carotid-Angio

– NA

Any other

– NA

Final Diagnosis

– Native triple vessel coronary artery disease. LIMA-LAD graft absent, SVG-LCX patent graft and significant disease in
SVG-LAD graft.

Recommendation

– PTCA with stenting to SVG-LAD graft

Procedure done

– PTCA was done through right femoral approach and good flow was achieved in SVG-LAD graft.

Procedural Details :

• PTCA was done through right femoral approach.
• 6F AR 1.0 guide catheter was used to engage the SVG to LAD graft.
• Asahi Sion Blue guide wire was taken to cross the lesion.
• Sequential pre dilatation was done with Ryurei 1.5 x 10 balloon at 12 atm and Ryurei 2.5 x 10 balloon at 14 atm,
  Yukon Choice PC 3.0 x 24 mm stent was deployed with the support of 6F Guidezilla supportive catheter at 12 atm.
• Stent boost guided sequential post dilatation was done with balloon Apollo 3.5 x 10 at 20 atm and Apollo 4.0 x 8
  balloon at 22 atm.
• Post dilatation was done with high pressure balloon OPN NC 2.5 x 10 at 36 atm.
• Post stenting IVUS was done for confirming the stent apposition with 3.0F Opticross HD IVUS catheter and the
  measured MSA was 5.30 mm2.

Pre-procedural findings

Details of Investigation (Findings) Post
Procedure:

ECG

• Sinus Rhythm.
• T wave inversion V1 – V4

ECHO

– Good LV systolic function

Condition at the time of discharge:

Stable

Discharge Advice:

• Tab ECOSPRIN 75 mg 1 tab once daily at 10 pm (Do not stop without doctor’s consultation).
• Tab CLOPITAB 75 mg tab twice daily at 10 am & 10 pm (Do not stop without doctor’s consultation).
• Tab ROZAVEL 40 mg 1 tab once daily at 10 pm.
• Tab FLAVEDON MR 35 mg 1 tab twice daily at 10 am and 10 pm.
• Tab KORANDIL 5 mg 1 tab twice daily at 10 am and 10 pm.
• Tab GALVUS MET (50/1000) 1 tab once daily at 10 am.
• Tab ZORYL M (1) 1 tab once daily before breakfast to continue.
• Tab CONCOR 2.5 mg 1 tab once daily at 10 am.
• Tab ESLO 2.5 mg 1 tab once daily at 10 pm.
• Tab DYTOR 10 mg 1 tab once daily at 8 am.
• Tab MUCINAC 600 mg 1 tab twice daily at 10 am and 10 pm for 5 days.
• Cap PAN-D 1 cap once daily before breakfast.

Instructions to watch for emergency:

Chest pain/discomfort, shortness of breath, syncope,
palpitation

General Advice:

• Proper medical management
• Oil, fat, salt restricted and diabetic diet

Follow-up

• Follow up after 30 days in Cardiology OPD with of CBC, FBS, PPBS, Na+, K+, Urea, Creatinine, ECG – 12 leads
  reports with prior appointment.
• In case of unwanted symptoms, visit Emergency department.

Discussion

Calcified non-dilatable lesions is a challenge for the interventional cardiologist. These lesions are developing
more often in the catheterization laboratory as the total complexity of interventions are increasing. Stent
under-expansion is the main risk factor for restenosis and thrombosis.1
The OPN NC balloon offers a new method of dilating lesions or under-expanded stents when other noncompliant
balloons have failed in the catheterization process. The safety of the OPN NC balloon is reasonable, even at pressures
as high as 40 atm.1

Ref: Díaz JF, Gómez-Menchero A, Cardenal R, Sánchez-González C, Sanghvi A. Extremely high-pressure dilation with a new
noncompliant balloon. Tex Heart Inst J. 2012;39(5):635-638.