A patient with prior CABG and prior PCI of the proximal LAD presented with recurrent angina. Coronary angiography showed mid LAD occlusion with the distal vessel filling via the LIMA, 90% proximal circumflex, an occluded OM1 that was filling via a patent SVG and an occluded mid RCA with ipsilateral bridging collaterals. Surprisingly, iFR of the circumflex was 0.93, whereas iFR of the mid LAD was 0.83, hence PCI of the LAD was attempted. The lesion was predilated with 2.0 and 2.5 mm balloons; a 2.5 mm balloon ruptured without causing any complications. We failed to deliver stents. The lesion was predilated with a 2.75 mm balloon, but delivery of an Angiosculpt balloon and a 3.0x40 mm Shockwave balloon failed. After using a guide catheter extension the Angiosculpt balloon was successfully delivered to the LAD and successfully inflated. Stents still could not be delivered. Repeat attempts to deliver the lithotripsy balloon failed and a stent was stripped off the balloon. The lost stent was successfully retrieved using the small balloon technique. Another stent was successfully delivered and deployed with a nice final result after postdilation with a 3.0 mm balloon as confirmed by IVUS.
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Case 107: PCI Manual - Finding and treating the culprit
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