1. 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

2. 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

3. 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

4. Catheter kinked in Right Radial during CAG

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

6. 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

7. PTCA and Stenting to RCA

8. 3rd day LM PTCA done. LCX-BMW, LAD-Mir3

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

10. 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