Onyx in post-CABG & post-PTCA patient with distal LMCA edge stenosis of stent

Case presentation

• 74 Year old Male patient appeared with recent onset of Angina.
• 1996 – CABG
• 2003 – LIMA to LAD occluded – AWMI – PTCA to osteal LAD [Penta stent]
• 2013 – Unstable angina – DE novo lesion of Mid LAD – PTCA [Resolute Endeavor]
• 2018 – Distal LMCA edge restenosis across the LCX, Patent R. Endevour stent. Osteal LCX 80% stenosis, OM diffuse disease, RCA mid segmet CTO.
• LIMA to LAD & SVG to OM Occluded. RIMA to RCA patent & post anstomosis PDA signicant stenosis.
• ADVICE – Redo CABG but refused by patient in view of high risk.

Diagnosis and treatment plan 

• Echo showed LV RWMA+ of LAD territory, FAIR LV function.
• Diagnosis: CAD –ACSNSTEMI, HTN+, Dyslipidemia.
• Procedure: PTCA 2 Stents to LMCA – Minicrush or DK crush
• Location: LMCA, LAD, LCX.
• Lesion Severity: Calcified, LAD osteal stent, High risk procedure.

Resolute onyx: how it made my case easy?

• Onyx showed excellent outcome in LMCA. There were no signs of residual stenosis or any edge dissection found. The final result was TIMI 3 flow.
• No occlusion or stenosis of LCx ostium – no plaque shift or carina shift.
• High risk angioplasty in unstable crashing patient made simple.
• Easy tracking of stent in calcified, restenosed LM-LAD lesion.

Conclusion

• The final result was good with TIMI 3 flow & no residual stenosis or dissection
• Provisional stenting is always a better option in such an unstable patient to bailout his symptoms.
• IABP should be standby option.

About Author –

Dr. Pankaj Vinod Jariwala, Consultant Interventional Cardiologist, Yashoda Hospitals – Hyderabad
MD, DNB, DNB, MNAMS, FICPS, FACC.
Fellowship in Interventional Cardiology [ICPS, Paris, France]He has performed 5000+ percutaneous trans-luminal coronary Angioplasty & 10,000+ Coronary Angiograms and treated 500+ structural heart diseases (including congenital) with Percutaneous Balloon Mitral Valvuloplasty [PBMV] and other pediatric & adult cardiac interventions.