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PCI for LAD – CTO, Coronary Perforation? PCI 开通 LAD-CTO 术中的冠脉穿孔？

PCI for LAD – CTO, Coronary Perforation? PCI 开通 LAD-CTO 术中的冠脉穿孔？. Tongku Liu The center of Cardiology, Affiliated Hospital of Beihua University, Jilin 132011, Jilin, China 北华大学附属医院心脏中心，刘同库 （原吉林医学院附属医院心脏中心）. Case Presentation(1). Clinical presentation (Medical record No. 201225136)

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PCI for LAD – CTO, Coronary Perforation? PCI 开通 LAD-CTO 术中的冠脉穿孔？

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  1. PCI for LAD – CTO,Coronary Perforation?PCI开通LAD-CTO术中的冠脉穿孔？ Tongku Liu The center of Cardiology, Affiliated Hospital of Beihua University, Jilin 132011, Jilin, China 北华大学附属医院心脏中心，刘同库 （原吉林医学院附属医院心脏中心）

  2. Case Presentation(1) Clinical presentation (Medical record No. 201225136) A 59 year-old male was admitted due to intermittent chest pain for two months, which was aggravated before one week. Indoor walking can induce the chest stuffy pain before one week. He was admitted to our hospital on 10th September 2012. Past medical history He suffered from AIM on 12th March 2011(before18 months)，and was treated with drug to recover comfortable state. He have been taking drug with aspirin and adalat and so on. But when he do activity he feel heart palpitations, shortness of breath and sometimes nocturnal paroxysmal dyspnea. Risk factor His risk factor was only smoking history for 20 years (1 pack/day). **男，59岁。（病例号201225136号）间断发作胸痛2个月，加重1周。 近1周于室内散步也可诱发心前区闷痛，于2012-9-10日入院。 既往：于2011年3月12日(18个月前)，因心前区痛持续不缓解在外医院 住院诊断为AMI，药物治疗好转。出院后一直口服药物治疗(阿司 匹林、硝苯地平等)，但活动时心悸、气短感及有时出现夜间阵发 性呼吸困难。 危险因素：吸烟史20年，（1包/日）；无高血压和糖尿病史。

  3. Case Presentation(2) Physical Examination T 36.2℃,P 62/min, BP:115/80mmHg（millimeter of mercury). The heart rate was 62 per minute. Cardiac auscultation showed that heart sounds was normal, and each valve area was without murmurs.The tiny bubbles sounds were heard in double lungs low . His liver was not big and lower limbs no swelling. T36.2，P62/min, BP:115/80mmHg, HR62/min,节律规整，各瓣膜区无明显杂音。双肺低少许湿啰音。肝不大。双下肢无浮肿。

  4. ECG QS in Ⅲ , aVF and v1-v3 T-wave V4-V5 was negative

  5. Echocardiography (ultrasonic cardiogram .UCG) LA 32mm LV 51mm AO 30mm RVOT31mm RV 18mm IVS 9.0mm LVPW 10.0mm EF 0.59

  6. Blood Routine Examination WBC 9.98×10∧9 /L NEUT 63.64% RBC 4.69×109 ∧12/L HGB 153.0×G/L PLT 251.0×10∧9

  7. Blood biochemical examination Uric 460 umol/L Crea 75umol/L TG 2.08 mmol/L Chol 3.63 mmol/L cTn 0.00 ug/L

  8. Baseline coronary angiogram（1） LAO25° +CAU25° CAG showed LAD-CTO

  9. CAG（2） CRA 25° CAG showed LAD-CTO

  10. CAG（3） RAO30°+CRA25° LAD-CTO

  11. CAG（4） CRA30° CAG showed LAD-CTO lesions

  12. CAG（5） RAO30° CAG showed LAD-CTO

  13. CAG（6） CRA28° RCA collateral circulation to LAD

  14. CAG（7） LAO45° CAG showed collateral circulation from RCA to LAD

  15. The diagnosis The diagnosis: coronary heart disease, unstabler angina pectoris ，OMI ( anterior wall )and left cardiac insufficiency, heart function 2-3 grade He received aspirin and clopidogrel and underwent cardiac catheterization and PCI on 13th September 2012 诊断： 冠心病，不稳定型心绞痛, 陈旧性前间壁和下壁MI， LAD-CTO病变，慢性左心功能不全， 心功能2-3级 入医院开始服用阿司匹林和氯吡格雷， 于2012-9-13日行PCI for LAD-CTO

  16. Procedure of PCI（1） Radial artery way, XB3.5 guiding cath, micro catheter Miracle 3 wire, CAG showed micro cath was used 桡动脉路，XB3.5指引导管，在微导管的支持下，应用Miracle 3导丝，通过病变，推送微导管. 使用薇导管的CAG

  17. Process of PCI（2） True-lumen was confirmed by CAG with miro-cath

  18. Process of PCI（3） To further push forward miro-cath，CAG True-lumen was confirmed by CAG with miro-cath BMW replaced Miracle 3.

  19. Process of PCI（4） Replacement of BMW wire Maverick 1.5× 15 mm balloon was applied to dilate the lesions

  20. Process of PCI（5） CAG after the dilatation, distal LAD was occlusion and perforation was not found.

  21. Process of PCI（6） Distal LAD was dilated with 1.5× 15mm balloon

  22. Process of PCI（7） After distal LAD was dilated with 1.5× 15mm balloon, What happen? Perforation? Please to discuss it.

  23. Process of PCI（8） Perforation ！ Small balloon was immediately applied to plug LDA distal

  24. Process of PCI（9） CAG after 10 min to plug it showed flow of contrast.

  25. Process of PCI（10） CAG after 20 min to plug it showed contrast agent through the hole sprayed outward . Protamine 75.0 mg was applied immidetely

  26. Process of PCI（11） Protamine 75.0 mg was applied immidetely. at the same time the Balloon was inflated to plug the vessel.

  27. After 20 minutes, CAG showed the distal LAD was blockage.PCI was stopped. The patient went back to the ward. Process of PCI（12）

  28. So far, a coronary artery perforation is still considered 冠脉穿孔分型 Perforation?

  29. PCI was stopped. The patient went back to the ward .The vital signs of patient was closely monitored for lasting one week. The patient’s vital signs was stable .

  30. 8天后(2012-9-21)再次CAG示LAD通畅，LAD远端仍有造影剂外流，仔细观察是LAD-LV漏所致影像。8天后(2012-9-21)再次CAG示LAD通畅，LAD远端仍有造影剂外流，仔细观察是LAD-LV漏所致影像。 Process of PCI（13） Eight days later (2012-9-21), again to do the CAG. The CAG showed unobstructed LAD. Distal LAD still had contrast to outflows, careful observation is LAD - LV images caused by leakage.

  31. RCA CAG（14） CRA 28° Eight days later(2012-9-21), again to do the CAG.LAD-LVleakage was recognized.

  32. Procedure of PCI（15） Per-dilatation with2.0×20mm Maverick balloon

  33. Procedure of PCI （16） BuMa stent 3.0 × 20mm was implanted in middle LAD

  34. Procedure of PCI （17） BuMa stent 3.0×20 mm was implanted in proximal LAD

  35. Procedure of PCI（18） BuMa stent 3.0 ×15 mm was implanted in ostial LAD

  36. Final Result after stenting Procedure of PCI （19）

  37. Procedure of PCI （20） Final Result

  38. Procedure of PCI （21） Final Result

  39. Procedure of PCI （22） Final Result

  40. ECG After the Procedure

  41. The examination of lipid and myocardial enzyme after the procedure

  42. Ion and renal function tests after the procedure

  43. 讨论 (Discussion) 1、冠脉穿孔的识别与处理 2、冠状动脉-心室漏的识别与处理 3、PCI开通CTO病变中的注意事项。 1, The identification and treatment of coronary perforation. 2, Recognition and treatment of coronary artery-ventricle leak 3, Attention of PCI - CTO lesions

  44. Thank you for your attention 报 告 者: 刘同库；E-Mail:liutongku20102163.com;电话：18943209667 单 位: 北华大学附属医院心脏中心 通信地址：吉林市解放中路12号，北华大学附属医院心脏中心

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