pci for lad – cto, coronary perforation? pci 开通 lad-cto 术中的冠脉穿孔？ tongku liu...

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) A 59 year-old male was admitted due to intermittent chest pain for two months, which wa

s 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 dru

g 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。

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。

ECGQS in Ⅲ , aVF and v1-v3

T-wave V4-V5

was negative

Echocardiography (ultrasonic cardiogram .UCG)

LA 32mm

LV 51mm

AO 30mm

RVOT31mm

RV 18mm

IVS 9.0mm

LVPW 10.0mm

EF 0.59

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∧

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

Baseline coronary

angiogram（ 1 ）

LAO25°+CAU25°

CAG showedLAD-CTO

CRA 25°

CAG showed LAD-CTO

CAG（ 2

）

RAO30°+CRA25°

LAD-CTO

CAG（ 3

）

CRA30°

CAG showed LAD-CTO lesions

CAG（ 4 ）

RAO30°

CAG showed LAD-CTO

CAG（ 5

）

CRA28°

RCA collateral circulation to LAD

CAG（ 6

）

LAO45°

CAG showed collateral circulation from RCA to LAD

CAG（ 7

）

The diagnosis

The diagnosis: coronary heart disease, unstabler angina pectoris ， OMI ( anterior w

all )and left cardiac insufficiency, heart function 2-3 grade He received aspirin and clopidogrel and underwent cardiac catheteriza

tion 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

Procedure of PCI （ 1 ）

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

Radial artery way, XB3.5 guiding cath, micro catheterMiracle 3 wire,

CAG showed micro cath was used

Process of PCI （ 2 ）

True-lumen was confirmed by CAG with miro-cath


True-lumen was confirmed by CAG with miro-cath

BMW replaced Miracle 3.

To further push forward miro-cath ， CAG

Process of PCI（ 4 ）

Replacement of BMW wire

Maverick 1.5

× 15 mm balloon was applied to dilate the lesions


CAG after the dilatation,

distal LAD was occlusion and perforation was not found.


Distal LAD was dilated with 1.5× 15mm balloon


After distal LAD was dilated with 1.5× 15mm balloon,

What happen?

Perforation?

Please to discuss it.

Process of PCI

（ 8 ）

Small balloon was immediately applied to plug LDA distal

Perforation ！


CAG after 10 min to plug it showed flow of contrast.


CAG after 20 min to plug it showed contrast agent through the hole sprayed outward .

Protamine 75.0 mg was applied immidetely

Protamine 75.0 mg was applied immidetely.at the same time the Balloon was inflated to plug the vessel.


After 20 minutes, CAG showed the distal LAD was blockage.

PCI was stopped. The patient went back to the ward.


So far, a coronary artery perforation

is still considered

冠脉穿孔分型

Perforation?Perforation?

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 .

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。

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.


RCACRA 28°

Eight days later(2012-9-21), again to do the CAG.LAD-LV leakage was recognized.

CAG（ 14 ）

Per-dilatation with2.0×20mm Maverick balloon

Procedure of PCI （ 1

5 ）

BuMa stent 3.0 × 20mm was implanted in middle LAD

Procedure of PCIProcedure of PCI（（ 1616 ））

BuMa stent 3.0×20 mm was implanted in proximal LAD

Procedure of PCIProcedure of PCI（（ 1717 ））

BuMa stent 3.0 ×15 mm was implanted in ostial LAD

Procedure of PCI （ 18 ）

Final Result after stenting

Procedure of PCIProcedure of PCI （（ 1919 ））

Final Result


ECG After the Procedure

The examination of lipid and myocardial enzyme

after the procedure

Ion and renal function tests after the procedure

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

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

pci for lad – cto, coronary perforation? pci 开通 lad-cto 术中的冠脉穿孔？ tongku liu...

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