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Selective angiography showing chronic total occlusion of the left subclavian artery (arrow).
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In view of the deteriorating echocardiographic picture (suggestive of likely stunned anterior wall myocardium), he was transferred to the catheterization laboratory, where a chronic total occlusion of the left subclavian artery proximal to the origin of the LIMA was seen (Figure 1).
Coronary angiography showing severe lesion of distal left main stem (arrow) and retrograde filling of left internal mammary artery (asterisks).
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The two SVGs were patent whereas the LIMA was seen filling retrogradely through the native coronary images (Figure 2).
(A) Coronary angiography after percutaneous coronary intervention (white arrow). White asterisks denote left internal mammary artery retrograde filling. (B) Angiography of left subclavian artery distal to chronic total occlusion (arrow). Asterisks denote inflated compliant balloon for transient left internal mammary artery occlusion.
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To improve the coronary flow down the LAD territory percutaneous coronary intervention (PCI) was performed with the implantation of a new-generation sirolimus-eluting stent in the LMS-LAD (Orsiro, Biotronik, Inc., Germany) followed by paclitaxel-eluting balloon inflation in the proximal circumflex artery (SeQuent Please, B Braun, Germany) (Figure 3).
Coronary angiography showing patent left internal mammary artery and retrograde filling from left anterior descending after coils deployment (arrows denote coils).
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Since complete occlusion was not achieved with coils (Figure 4), the operators elected to also implant a Micro Vascular Plug (5.3 x 12 mm) device in the mid-LIMA (Figure 5).
Complete occlusion of left internal mammary artery after plug implantation (arrow).
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Since complete occlusion was not achieved with coils (Figure 4), the operators elected to also implant a Micro Vascular Plug (5.3 x 12 mm) device in the mid-LIMA (Figure 5).