Volume 1 issue 1

Table of Content

Bailout Bifurcation strategy in Primary PCI

Muhammad Waqas Mazhar, Khawaja Ehtesham Ahmed & Omar Rafifan Alanazi


Background: Primary percutaneous coronary intervention (PCI) is a critical procedure for managing acute ST elevation myocardial infarction (MI). Bifurcation lesions, in particular, pose unique challenges during PCI, necessitating specialized strategies to optimize procedural success and minimize adverse outcomes.

Case Presentation: We present a case of a 60-year-old male with a history of hypertension who presented with acute anterior ST elevation MI complicated by acute atrial fibrillation at 2 AM. Coronary angiography revealed acute proximal to mid total occlusion of the left anterior descending artery (LAD) and a large first diagonal branch. Despite encountering challenges during the procedure, including the need for bailout bifurcation stenting, successful restoration of normal sinus rhythm was achieved with electrical cardioversion.

Management & Results: The patient was discharged after 72 hours and scheduled for staged PCI to the right coronary artery. The use of the inverse culotte technique in this case highlights the importance of meticulous angiographic assessment and adaptability in managing unexpected complexities during primary PCI.

Conclusion: Follow-up revealed stable clinical outcomes, emphasizing the significance of comprehensive post-procedural care and long-term medication adherence. Additionally, discussions underscore the technical considerations and potential limitations associated with culotte stenting, particularly in cases with narrow bifurcation angles.

Mini Crush with Rota Ablation

Saleha Haroon


Background:  Coronary artery disease (CAD) remains a significant cause of morbidity and mortality worldwide, particularly in elderly individuals. Complex coronary lesions, such as bifurcation disease with calcific plaques, further exacerbate the treatment dilemma, necessitating innovative approaches to revascularization.

Case Presentation: An 85-year-old frail male, normotensive and normoglycemic, presented with non-ST segment elevation myocardial infarction (NSTEMI). Angiogram revealed triple vessel disease, with particularly critical involvement of the distal left main stem (LMS) and complex bifurcation disease in the proximal left anterior descending artery LAD and ostioproximal course of Ramus intermedius. Despite referral for coronary artery bypass grafting (CABG), surgical intervention was deemed unsuitable due to the patient’s advanced age and frailty.

Management & Results: The patient underwent mini crush bifurcation stenting from LMS to LAD and Ramus intermedius, preceded by rota ablation of the calcific LAD lesion. The final outcome, assessed by intravascular ultrasound (IVUS) imaging, demonstrated optimal results.

Conclusion: In elderly, frail patients with triple vessel coronary artery disease (TVCAD) who are unsuitable candidates for surgery, complex bifurcation stenting can be a viable option. However, meticulous lesion preparation and IVUS-guided revascularization are crucial, especially in cases involving left main stem bifurcation stenting, to improve procedural outcomes.

Navigating Unanticipated Complications in Percutaneous Coronary Intervention: A Case Report of Elective PCI Turning into Primary PCI for RCA Stenosis

Maryam Ashraf


Background: Percutaneous coronary intervention (PCI) is a cornerstone in the management of coronary artery disease, offering a minimally invasive approach to restore blood flow in obstructed coronary arteries. However, unexpected complications can arise during these procedures, necessitating rapid adaptation and intervention to ensure optimal patient outcomes.

Case Presentation: We present the case of a 73-year-old male with effort angina and multiple comorbidities, including diabetes mellitus, hypertension, and dyslipidemia. Scheduled for elective PCI due to a moderate-tight lesion in the proximal right coronary artery (RCA), the procedure swiftly transitioned into a primary PCI scenario following abrupt vessel closure and ST-segment elevation. Diagnostic assessment revealed the need for immediate intervention to address potential causes such as thrombus, dissection, or air embolism.

Management & Results: A multidisciplinary team employed a systematic approach, utilizing aspiration thrombectomy, stent placement, balloon dilatation, and intracoronary medications to restore coronary flow and manage complications. Despite challenges including hypotension and bradycardia, sequential interventions successfully addressed thrombus burden and ostioproximal dissection. Pharmacological agents were administered to optimize coronary perfusion, leading to improved antegrade flow with residual haziness in distal vessels.

Conclusion: This case underscores the complexity of managing unanticipated complications during PCI, emphasizing the importance of rapid recognition, multidisciplinary teamwork, and advanced interventional techniques. Through meticulous assessment and targeted interventions, optimal outcomes can be achieved, highlighting the critical role of preparedness and adaptability in navigating PCI procedures.

Wasim Sajjad & Jabar Ali


Background: Left main artery disease (LMAD) poses a significant risk to patients, often leading to complications such as chest pain and hypotension with high mortality rates. Prompt and proper management is essential for improving outcomes in these cases.

Case Presentation: A 50-year-old lady with hypertension and diabetes presented with ST-segment elevation myocardial infarction (STEMI) refractory to thrombolysis, complicated by severe LV dysfunction. Coronary angiography revealed LMAD involving the LAD and LCx arteries.

Management & Results: High-risk percutaneous coronary intervention (PCI) under intra-aortic balloon pump (IABP) support was performed, resulting in successful stenting of the LMAD and improvement in symptoms and LV function.

Conclusion: This case highlights the importance of timely intervention and the role of IABP-assisted PCI in managing LMAD with severe LV dysfunction, emphasizing the need for a simplified approach and adherence to optimal medical therapy.

Chronic Total Occlusion of Left Main Stem with Multi-vessel Disease

Irfan Muhammad


Background: Chronic total occlusion (CTO) of the left main stem (LMS) presents a challenging scenario in the management of coronary artery disease. We present a case highlighting the successful intervention and long-term outcomes in a 70-year-old male with CTO of the LMS and multi-vessel disease, complicated by non-ST-segment elevation myocardial infarction (NSTEMI) and severely impaired left ventricular (LV) function.

Case Presentation: A 70-year-old hypertensive male presented with NSTEMI, severe LV dysfunction, moderate mitral regurgitation, and hypotension. Despite initial hesitation towards intervention, recurrent chest pain necessitated urgent coronary angiography. Diagnostic assessment revealed electrocardiographic changes suggestive of ischemia and echocardiographic evidence of LV dysfunction.

Management & Results: Therapeutic intervention involved meticulous pre-dilatation of the occluded LMS followed by angioplasty and stenting, with attention to avoid bifurcation stenting. Additional interventions included balloon angioplasty and stenting of proximal lesions in the left anterior descending (LAD) artery and ramus, and direct stenting of the distal right coronary artery (RCA) lesion. Long-term follow-up demonstrated significant improvements in clinical symptoms and LV function, emphasizing the efficacy of revascularization.

Conclusion: This case underscores the importance of timely intervention, tailored therapeutic approaches, and long-term medication adherence in optimizing outcomes in patients with complex coronary artery disease and impaired LV function. A simplified approach to multi-vessel percutaneous coronary intervention may offer favorable long-term outcomes, warranting further investigation.

Advancements in the Management of Coronary Perforation: A Case Report Demonstrating Effective Strategies and Favorable Outcomes

Qazi Muhammad Tufail


Background: Coronary perforation, historically considered a perilous complication in interventional cardiology, has seen remarkable advancements in its management. Timely identification and intervention are pivotal in mitigating adverse outcomes associated with this complication.

Case Presentation: We present the case of a 63-year-old female with exertional angina and multiple comorbidities, who underwent coronary angiography revealing proximal chronic total occlusion in the right coronary artery and focal tight mid-stenosis in the left anterior descending artery. Post-dilatation in the latter resulted in grade III perforation, necessitating immediate intervention.

Management & Results: Prompt action was taken, including balloon tamponade and rapid deployment of a covered stent within the affected segment. This approach effectively sealed the perforation and restored distal flow, leading to favorable outcomes. The patient remained hemodynamically stable, with resolution of minimal pericardial effusion on serial echocardiograms.

Conclusion: This case highlights the transformative impact of advancements in the management of coronary perforation, emphasizing the importance of quick identification and decisive intervention. The utilization of covered stents offers a minimally invasive approach with favorable patient outcomes, underscoring the evolution in interventional cardiology practices.

Balloon-Related Complications in Coronary Angiography: Navigating the Perils of Aggressive Interventions

Junaid Babar


Background: In the realm of interventional cardiology, the pursuit of procedural perfection often confronts clinicians with the challenge of balancing efficacy with patient safety. This case report sheds light on the potential hazards of aggressive post-dilatation techniques in coronary angiography, emphasizing the imperative of recognizing and managing balloon-related complications promptly to ensure optimal patient outcomes.

Case Presentation: A 70-year-old female presented with Non-ST Segment Elevation Myocardial Infarction (NSTEMI) and triple vessel coronary artery disease (3VCAD), necessitating multi-vessel percutaneous coronary intervention (PCI). Despite successful intervention in the right coronary artery (RCA), complications arose during PCI to the left anterior descending artery (LAD), highlighting the risks associated with aggressive procedural approaches.

Management & Results: Following unsuccessful post-dilatation attempts in the LAD, the patient experienced severe chest pain and hemodynamic instability, necessitating emergent measures to avert catastrophic outcomes. Prompt recognition and management of balloon-related complications facilitated the stabilization of the patient, ultimately culminating in a trajectory of satisfactory recovery with resolution of symptoms.

Conclusion: This case underscores the importance of exercising caution in the pursuit of procedural perfection, particularly in the context of coronary interventions. Balancing the imperative of achieving optimal procedural outcomes with the paramount goal of ensuring patient safety is pivotal in navigating the complexities inherent to interventional cardiology practice. Embracing a philosophy that acknowledges the limitations of aggressive techniques and prioritizes patient well-being lays the foundation for enhanced clinical outcomes and improved quality of care.