Crescendo angina in Distal Left Main CTO Dr AM Thirugnanam, MD, FSCAI, Phd, Director of interventional cardiology Ipcard cardiac care center,hyderabad, india Crt2017, washington dc

Patient History 75 years old man had Hypertension for 15 years Non smoker, non alcoholic, Non Vegetarian No surgical history, Limited physical activity Had occasional chest discomfort for 2 years

Physical Examination/ Investigations BP-100/160mmhg, HR-86/min, Saturation-95% at room air. Lungs-mild bilateral crepitation, Pulse- normal volume. ECG- ST-T changes in all leads LVEF-45% with Global Hypokinesia RBS-105 mg, Cr-1.2, cTnI-1980ng/dl, USG Abdomen- mild enlargement of Prostate, PSA- Normal

Catheter kinked in Right Radial during CAG

CAG-LM distal-70-100%, RCA-60%-96% Left system Right system

Complications during CAG Patient Developed severe angina and hypotension We decided to do Stenting to RCA first and then LAD Ecosporin-325mg, Clopidogrel-300mg, Atorvastatin-80mg, Bolus Infusion of Bivalirudin Continuous infusion of Bivalirudin during PTCA

PTCA and Stenting to RCA

3rd day LM PTCA done. LCX-BMW, LAD-Mir3

LAD-33/3.0 mm, LM-3.5/28mm Xience-Exp

Final results after Post Dilatation of LM/LCX Conclusion: Procedural complications and High risk CAD poses more mortality Staged and meticulous planning will assure best results