Excerpt

A 46-year-old patient had coronary angiography in 2008 for left ventricular dysfunction accompanied by acute embolic occlusion of the left external iliac artery. One week before hospitalization, he suffered a blow to the anterior chest during karate. The coronary angiogram revealed a slit-like lesion in the first septal branch, the second diagonal branch (DB) and the mid-left anterior descending coronary artery (LAD). Thereafter, he had no subjective symptoms and did not require medications or additional hospital visits. In August 2017, he presented to our hospital with right-sided leg pain. His coronary risk factors were smoking, hypertension, and dyslipidemia. We diagnosed acute limb ischemia due to an embolism from a left ventricular mural thrombus using cardiac MRI, enhanced CT, and ultrasound cardiography (UCG). After surgical therapy with a Fogarty arterial embolectomy catheter, we reassessed the coronary lesion using multiple modalities. Coronary angiography revealed thin channels, which joined distally in the LAD including the septal and second diagonal branches (Fig. 1a-1). Additionally, we performed invasive measurement of fractional flow reserve (FFR) with intracoronary papaverine administration. The FFR value in the LAD was 0.74. We performed intravascular ultrasound (IVUS) (Fig. 1a-2) and optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) to the LAD. First, we performed excimer laser coronary angioplasty (ELCA) (0.9 mm, 60 mJ, 60 pulses) only after wiring to confirm the effectiveness of treating the membrane-like lesion. We used three wires to protect and destroy the lotus root-like lesion in the 2nd and 3rd DBs. Then, we performed ELCA (0.9 mm, 80 mJ, 80 pulses) again around the main vessel and 2nd diagonal branch. Thereafter, we confirmed the destruction of the lotus root-like lesions by OCT. The lesion in the 2nd DB was not derived from the membrane-like lesion in the main route. ELCA was very effective in destroying the membrane-like stenotic lesions, and there was no side branch (SB) occlusion (Fig. 1b). We successfully deployed drug-eluting stents after ballooning without SB occlusion (Fig. 1c). We treated the patient with triple therapy using dual antiplatelet drugs and warfarin after PCI. Follow-up UCG revealed slight wall motion recovery with severe apical hypokinesis.

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