CASE PRESENTATION

Heavy Calcified Tight Lesion & CTO

By
Dr. Hafid
Post Fellow
 Sequence
• Introduction
• Clinical History
• Clinical Examination
• Labs
• Images
• Discussion
• Follow-up
 Clinical History
• 60 Years
• Chest pain in activity
• Known case of diabetes mellitus for 10 years
• Know case of hypertension for 10 year
• 1ST DCA (PCI CTO distal RCA), June 2017.
– Long lesion heavy calsified Osteal to mid
LAD, stenosis up to 80%
– Stenosis Osteal to proximal LCX up to 80%
 Clinical Examination
• Pulse 72 beats/min
• BP 120 / 70 mmHg
• RR 20 breaths/min
• ECG Sinus rhythm 72x/m,
Incomplete RBBB, CAD OMI
Inferior.
 Labs
• Hb 11.6 • PPT 10.6
• WBC 7.61 • APPT 22.7
• Plt 261.000 • HbsAg Non-reactif
• BUN 24
• SK 1.64
 Data-data
• Ro Thorax :
– Cardiomegali, CTR 64%

• Echocardiography :
– LV Hypokinetik, EF 64%
 Previous DCA & PCI
• June 16, 2017
• DCA
– LMCA : Stenosis 50% distal LMCA
– LAD : Stenosis 80% from osteal to mid LAD
– LCx : Stenosis 70% Osteal LCX
– RCA : CTO distal RCA, collateral from LCX
• PCI
– CTO distal RCA
 Summary
• 60 yrs pts with with left Coronary complex,
heavy calcified lesion
• Recommended for Staging PCI
 Staging PCI
• August 23, 2017, at DR Soetomo Hospital
• DCA
– LMCA : Normal
– LAD : CTO Osteal LAD
– LCX : Stenosis 80% Osteal LCX, CTO distal
after OM2
– RCA : Not evaluated
LAO Caudal Projection
RAO Cranial Projection
Wiring
Atherectomy Rotablation
Rotablation Atherectomy
After Rotablation
Balloon predilatation
GC ST01 5F within GC EBU 3.5 7F
Mother and Child Technique
Stent Positioning
Stenting Osteal LCX
Video 45
Stenting Osteal LAD
Final result
 PTCA Procedure
• GC Canulation
• Wiring
• Ballooning
• Rotablation Atherecthomy
• Mother n Child technique, Stent Insertion
• V Stenting
THANKS
 PTCA
heparin 5500 IU '
GC EBU 3.5 7F menuju aorta ascenden, engaged di ostium LMCA
GW Runtrough Hypercoat menuju distal LAD, berusaha menembus
lesi, usaha berhasil, GW Standby.
GW Runtrough Hypercoat menuju distal LCx, berusaha menembus
lesi, usaha berhasil, GW Standby.
Ballon Mozec NC ukuran 2.5 x 15 mm menuju osteal - proximal LAD
dilakukan dilatasi 12atm/10sec, 12atm/8sec, 12atm/83ec,
12atm/7Sec, 13atm/8Sec, 14atm/7Sec, 14atm/8sec,
14atm/7Sec. Pull out ballon.
Ballon Sapphire ll ukuran 1.5 x 12 mm menuju mid LAD dilakukan
dilatasi 10atm/1OSec, 10atm/6Sec, 10atm/6Sec, 10atm/6sec,
10atm/63ec, 10atm/6sec, 10atm/6sec, 10atm/6Sec. Pull out
ballon.
Ballon Mozec NC ukuran 2.5 x 15 mm menuju proximal - mid LAD
dilakukan dilatasi 12atm/9Sec, 14atm/9Sec, 12atm/103ec,
14atml9Sec, 1Zatm/8sec, 12atm/7sec, 18atm/10Sec,
18atm/10Sec, 18atm/10sec, 18atm/73ec, 18atm/9Sec,
18atm/9Sec, 18atml8sec, 18atml9Sec, 18atml8Sec,
18atm/83ec, 20atm/10Sec, 20atm/10Sec. Pull out ballon.
Dilakukan rotablasi di proximal - mid LAD dengan kecepatan 180 -
200 RPM berusaha menembus lesi, usaha berhasil.
Ballon Mozec NC ukuran 2.5 x 15 mm menuju proximal - mid LAD
dilakukan dilatasi 18atm/9Sec, 20atlesec, 24atm/9Sec,
24atm/7Sec. Pull out ballon.
isocath 1 mg intrakoroner, heparin 1000 IU intravena.
Ballon Mozec NC ukuran 2.5 x 15 mm menuju osteal - proximal LCx
dilakukan dilatasi 24atm/Qsec, 24atm/8sec, 20atm/73ec,
20atm/8sec, 24atm/8sec. Pull out ballon.
Ballon Mozec NC ukuran 3.0 x 13 mm menuju proximal - mid LAD
dilakukan dilatasi 12atm/7Sec, 16atm/103ec, 16atm/8Sec,
16atm/83ec, 14atm/83ec, 16atm/93ec,
GC ST01 5F berada di dalam GC EBU 3.5 7F (Mother and Child).
Stent DES ALEX (Sirolimus) ukuran 2.75 x 18 mm menuju mid LAD,
dilakukan dilatasi 20atm/17sec, ballon extent ditarik ke
proximalnya, post dilatasi 14atm/10Sec. Pull out ballon extent
Stent DES ALEX (Sirolimus) ukuran 3.0 x 16 mm menuju osteal-
proximal LCx, dilakukan dilatasi 12atm/10Sec, 16atm/10Sec.
Pull out ballon extent.
heparin 2000 IU intravena Masuk
Stent DES Xlimus (Sirolimus) ukuran 3.0 x 16 mm menuju proximal
LAD overlapping dengan stent di distalnya, dilakukan dilatasi
16atm/8sec. Pull out ballon extent.
Prosedur selesai, pullout semua alat, selama dan sesudah tindakan
tidak didapatkan komplikasi.