ACS with cardiogenic shock on top of ambiguous, non crossable, non dilatable CTO-Bifurcation and tortuous lesion

When a type I DM presented with silent anteriorwall STEMI

ACS with cardiogenic shock on top of ambiguous, non crossable, non dilatable CTO-Bifurcation and tortuous lesion

Clinical Presentation

Present history: 70 years old female patient presented with nausea and vomiting

Hemodynamic: cardiogenic shock, stable rhythm

ABG parameters: Blood suger 250 mg/dl, lactate 3,7 mmol/l, PH 7,54,PCO2 25 mmHg, HCO3 23 mmol/l, BE -5,6 mmol/l

ECG:ST elevation V1-V5, AVR and AVL, ST depression II,III and AVF

Echocardiography: preserved LV-Funktion, EF ca. 65%

Coronarangiography: Three vessel  disease, LAD, RIM and RCA

RIM: 99% stenosis, Where is the LAD?, RCA: multiple 99% stenosis

Where is the LAD ostium? More projections to understand the anatomy

In order to wire the ambiguous ostial lesion, we did

•       Different angulation;

•       Wiring of neighboring vessel as a marker;

•       Blind surfing and

•       Side branch plaque modification

Ambiguous, non crossable, non dilatable CTO-Bifurcation and tortuous lesion, What next?

Rewiring in LAD

Rotablation in ACS?

Balloon grenadoplasty and after angioplasty

D1 no flow

New vessel, LAD? Or septal?

End result with more LAD projections

What next? High grade stenosis of carotis, abdominal and femoral arteries

Asymptomatic high-grade stenosis of the ACI on both sides (NASCET 80%)

Moderate stenosis of the left subclavian and left common carotid arteries          

High-grade stenosis of the coeliac trunk                              

Lusoria artery with retro esophageal course and 50% stenosis

High grade stenosis of both iliac and femoral arteries

What next?

Endovascular endarterectomy then Bypass OP or Staging PCI ?

We did staging PCI

Would do you do Rotabaltion? And or MCS with Impella ? 

Take home

•       CTO techniques are of value in some acute coronary syndrome scenarios

•       IVUS guided puncture, wiring of neighbouring vessel as a marker, different angulation, blind surfing and side branch plaque modification may help in ambiguous ostial lesion

•       Rotablation in acute coronary syndrome is risky but could be mandatory

•       Even young patient with three vessel disease are not always suitable candidate for surgery or mechanical circulatory support, especially in case of severe peripheral and carotis arterial disease