PP-441 - Unseen Part of the Iceberg Before Obesity Surgery: Multivessel Coronary Artery Disease

Abstract

Case report: 47 years old man evaluated for class II exertional dsypnea before obesity surgery as an outpatient. He had a history of hyperlipidemia and smoking with 30 packs a year. Physical examination revealed obesity (body mass index 36.2 kg/m2, 120 kg, 1.82 cm). Electrocardiography demonstrated sinus rhythm, and left anterior hemiblock. Echocardiography demonstrated normal systolic function, and mild mitral regurgitation. Due to the exertional dyspnea, he underwent myocardial perfusion scintigraphy which is showed myocardial ischemia of inferior and anterior myocardial wall. The coronary angiography showed severe stenosis of proximal left anterior descending and circumflex coronary artery. The retrograd collaterals from left coronary system to right coronary artery and total occlusion and antegrad bridge collaterals at proximal right coronary artery were also demonstrated in left and right coronary angiography. Coronary bypass surgery recommended for the complete revascularization but the patient didn't accept the surgery. First, the opening of the chronic total occlusion of right coronary artery, and then left coronary system were planned. 7F JR4 guiding, and 6F JL4 diagnostic catheters used for dual injection. The conus branch was use to anchor with 1,5 × 15 mm semi-compliant balloon. Gaia-3 guidewire was used to advance proximal cap under back-up with Corsair microcatheter and using drilling technique. By using Gaia 3 guidewire we weren't able to enter from distal cap to true lumen. Therefore, microcatheter changed to Twinpass microcatheter and the Fielder FC was used to enter acute margine branch or distal right coronary artery. Fielder FC was penetrated into the acute margine branch, and distal cap was punctured with the Conquest Pro through the side hole of the Twinpass microcatheter by advancing wire into the distal right coronary artery. By using TRAP technique, Twinpass microcatheter was removed and Corsair microcatheter was advanced into distal right coronary artery to protect coronary perforation by Conquest Pro manipulation. Grand Slam guidewire was advanced through Corsair microcatheter. After removing Corsair microcatheter by TRAP technique, multiple balloon dilatations were performed. 3.0 × 48 mm Xience Pro and 3.0 × 38 mm Cre8 DES were implanted mid-distal right coronary artery while 3.5 × 23 mm Xience Pro was implanted proximally. Multiple post-dilatations were performed with 3.5 × 18 mm non-compliant balloon and TIMI III flow was achieved. The revascularization of left coronary system was planned for two weeks later. Firstful, 4.0 × 26 mm Resolute stent was succesfully implanted to circumflex coronary artery. At the same procedure, 4.0 × 38 mm Resolute stent was succesfully implanted to the left anterior descending coronary artery. Control coronary angiography of the right coronary artery also showed that TIMI III flow with no evidence of thrombosis or stenosis. He discharged with the advice of the lifestyle changes, quit smoking, and weight lost. The obesity surgery was postponed until the 6 months from the procedure for reducing stent thrombosis risk.