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Technical Mastery: Guidance on Proper Imaging, Les ...
Slides, Dr. Rab
Slides, Dr. Rab
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This case involves a 60-year-old male patient presenting with an acute coronary syndrome (NSTEMI) characterized by dynamic inferolateral T wave changes and elevated troponin levels. The patient has significant comorbidities including metastatic male breast cancer treated with mastectomy, chemotherapy, and radiation to the chest, making him unsuitable for coronary artery bypass grafting (CABG). Multivessel coronary artery disease involving small caliber vessels (LCX/OM2) and long lesions with complex bifurcations posed a therapeutic challenge.<br /><br />Intervention included intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in the proximal to mid left anterior descending artery and the second diagonal branch. For the de novo lesions in small vessels of the left circumflex and OM2 branches, drug-coated balloon (DCB) angioplasty was chosen. This approach was preferred to avoid stenting ostial LCX lesions that risked extension into the left main coronary artery, which was contraindicated.<br /><br />After pre-dilation with scoring balloons, paclitaxel-coated DCBs were applied for 90 to 180 seconds. Post-procedure angiography showed non-flow limiting type B dissections which were accepted without additional stenting, consistent with healing potential and old balloon angioplasty principles. The patient tolerated the procedure well without complications or ischemic symptoms.<br /><br />He was discharged on dual antiplatelet therapy (aspirin and prasugrel) for 10 months alongside guideline-directed medical therapy. Planned follow-up angiography at three months will reassess and possibly treat residual right coronary artery disease with DCB. This case highlights the use of imaging-guided DCB in complex small vessel, long lesion, and bifurcation scenarios where stenting poses significant risks, supporting DCB as a viable alternative in selected high-risk patients.
Keywords
acute coronary syndrome
NSTEMI
intravascular ultrasound
percutaneous coronary intervention
drug-eluting stents
drug-coated balloon angioplasty
small vessel coronary disease
complex bifurcation lesions
dual antiplatelet therapy
male breast cancer comorbidity
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