PMC4004630_01
Electrocardiogram showing diffuse ST depressions in the precordial leads and mild ST elevation in lead AVR. There is also isolated 1 mm ST elevation in lead III with non-pathologic Q waves in the inferior leads.
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F1
The patient was subsequently intubated for airway protection, loaded with intravenous amiodarone, and an electrocardiogram (EKG) was obtained (Figure 1).
Coronary angiography. (A) A significant ostial left main lesion is present. Severe pressure dampening occurred upon engagement with a 5F diagnostic Judkins left catheter. (B) The distal right coronary artery (yellow arrows) fills retrograde from left-to-right collaterals. (C) The right coronary has moderate-to-severe diffuse disease in the proximal segment followed by an occlusion (yellow arrow highlights the stump) in the mid-segment just after the takeoff of a ventricular marginal branch.
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F2
Angiography demonstrated a concentric 95% stenosis involving the ostial left main artery (Figure 2A); the remaining left coronary system had diffuse irregularities without significant disease. Left-to-right collaterals supplying the distal right coronary artery were also noted (Figure 2B). Right coronary angiography demonstrated a diffuse 70% stenosis in the proximal segment followed by an occlusion in the mid-segment (Figure 2C).
Left main intervention (A) An 8F guide was selected to allow for both the pre-dilation balloon (solid yellow arrow) and stent (dashed yellow arrow) to be positioned side-by-side near the left main ostium. After rapid pre-dilation and balloon withdrawal into the guide, the stent was advanced quickly to the left main lesion and deployed. (B) After post-dilation with a 3.5 mm noncompliant balloon, the final angiographic result was excellent. Hemodynamics improved immediately.
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F3
The lesion was double-wired so that both the pre-dilation balloon and stent could be delivered in rapid, sequential fashion over separate wires (Figure 3A).