SS–12 Staged Percutaneous Revascularization of High-Risk Multivessel Coronary Artery Disease Involving Chronic Total Occlusion and a Complex Bifurcation Lesion: A Case Report

Abstract

Introduction and Aim: Although coronary artery bypass grafting (CABG) is the guideline-endorsed treatment for multivessel coronary artery disease in the presence of chronic total occlusion (CTO), staged percutaneous coronary intervention (PCI) represents an effective alternative in patients who decline surgery or are unsuitable surgical candidates. In this case, we present successful percutaneous revascularization completed in three sessions in a patient with extensive, high SYNTAX score (39) coronary artery disease involving the left main coronary artery (LMCA), left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA), who declined CABG.

Case Report: A 68-year-old male patient’s myocardial perfusion scintigraphy (MPS) performed prior to angiography revealed a fixed defect (scar) in the apex, apical anterior wall, inferior wall apical-mid-basal segments, and mid-basal inferoseptal wall, with no significant findings in favor of ischemia. Coronary angiography demonstrated 70–80% stenosis in the distal LMCA, 100% occlusion (CTO) of the LAD, 70–80% stenosis in the first diagonal branch (D1), 80–90% stenosis in the Cx, 80–90% stenosis in the third obtuse marginal branch (OM3), and 80–90% stenosis in the RCA. As the patient, for whom CABG was recommended, declined surgery, staged PCI was planned. In the first session, the RCA ostium was engaged, and the critical lesion was crossed with a floppy guidewire; near-complete patency was achieved following predilation with a 3.5×15 mm non-compliant (NC) balloon and implantation of a 4×20 mm drug-eluting stent (DES). In the second session, as the Cx lesion could not be crossed with a floppy wire, it was crossed with a Fielder XT-R wire under microcatheter support; following exchange for an extra-support wire and subsequent balloon predilations, a 2.75×38 mm DES was implanted, and post-dilation was performed with a 2.75×23 mm NC balloon. In the patient, who was considered at high surgical risk, the LAD CTO segment was crossed with various wires under microcatheter support during the third session, and the lesion was assessed with intravascular ultrasound (IVUS) following predilation. A 2.25×20 mm and a 2.75×24 mm DES were implanted in the LAD, and bifurcation stenting from D1 into the LAD was performed with a 2.75×24 mm DES using the mini-crush technique, followed by kissing balloon application. After post-dilation with NC balloons, mini-crush stenting was performed with a 3.5×12 mm DES in the LAD and a 3.5×20 mm DES from the LMCA into the Cx; final kissing balloon inflation was completed with 3.5×10 mm NC balloons, and the LMCA was post-dilated with a 4.5×8 mm NC balloon, achieving complete patency. No complications were observed. Echocardiography revealed an ejection fraction (EF) of 30–35%, dilated left ventricular (LV) dimensions, LV systolic dysfunction, and advanced hypokinesia in the basal-mid and apical segments of the inferior wall, the apicoseptal segment, and the apical segment of the anterior wall. Mild mitral regurgitation, trace aortic regurgitation, and mild tricuspid regurgitation were noted, and right heart structures were normal. The patient was discharged on trimetazidine, pantoprazole, doxazosin, metoprolol, acetylsalicylic acid, prasugrel, spironolactone, ramipril, and dapagliflozin.

Conclusion: In patients with high-risk multivessel coronary artery disease and CTO who decline surgery, IVUS-guided staged PCI performed with appropriate bifurcation technique may constitute a safe and effective revascularization strategy, resulting in complete patency without complications.

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