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CASE REPORT
CONTRIBUTING AUTHORS
■ ZAHER FANARI, MD Is a Cardiology Fellow in the Section of Cardiology at Christiana Care Health System in Newark, Del.
■ JHAPAT THAPA, MBBS is a Cardiologist in the Department of Cardiology at Christiana Care Health System in Newark, Del.
■ SUBBA R. VANGA, MBBS, MS is an Interventional Cardiology Fellow in the Department of Cardiology at Christiana Care Health System in Newark, Del. ■ WASIF QURESHI, MD is the Director of Structural Heart Disease in the Department of Cardiology at Christiana Care Health System in Newark, Del.
CASE DESCRIPTION
A 67-year-old male patient with a history of coronary artery bypass graft (CABG) eight years ago involving sequential saphenous vein graft to postero-lateral branch (PLB), posterior descending artery (PDA) and LIMA to LAD, presented with recurrent progressive angina. He also had a history of previous angioplasty and stenting to LAD distal to the touchdown, ischemic cardiomyopathy with left ventricular ejection fraction of 20 percent with cardiac resynchronization therapy device hypertension, hyperlipidemia, and diabetes mellitus.
Pharmacological nuclear myocardial perfusion imaging (MPI) showed the presence of new medium size fully reversible septal perfusion defect. Selective coronary angiography was performed via left radial artery approach using right and left Judkins-4 coronary catheter. Coronary angiography showed severe native three-vessel disease with patent sequential vein graft to PLB and PDA. LIMA to LAD graft had a 90 percent in-stent restenosis of the previously placed stent in the distal runoff (Figure 1).
A decision to perform percutaneous intervention (PCI) on the LAD stenosis distal to the LIMA touchdown was made. A ProWater Flex (Abbott Vascular, Abbott Park, Ill., USA) guide wire was advanced over a 6 French LIMA guide catheter and placed across distal LAD stenosis. The lesion was attempted percutaneous transluminal coronary angioplasty (PTCA) with a 2.0x12 mm balloon catheter without success due to watermelon seeding. Next, a 2.5×10 mm cutting balloon and cutting balloon atherectomy was performed twice with 50 percent residual proximal LIMA as well as left subclavian artery (Figure 2).
FIGURE 2
LIMA dissection with TIMI 0 flow to LAD.
FIGURE 3
Establishment of TIMI 3 flow with remnant ostial and mid LIMA dissection flaps.
Del Med J | June 2015 | Vol. 87 | No. 6
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