case_images: PMC7444146_01
case_images: Coronary angiography series in left coronary artery. (A) Significant left main true bifurcation lesion with severe calcification was revealed before percutaneous coronary intervention (PCI). (B) Post-initial PCI with only rotational atherectomy. (C) Post-bifurcation two-stenting with additional rotational atherectomy. (D) Angiographic follow-up at 1 year after bifurcation two-stenting.
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case_images: Then we performed emergent coronary angiography, which revealed left main true bifurcation lesion (LMTBL) (Medina classification 1-1-1) and severe stenosis in the mid-left anterior descending artery (LAD) with severe calcification (Figure 1A). The procedure was successfully finished with TIMI grade 3 flow using verapamil, nicorandil, and nitroprusside (Figure 1B). Integrity 3.0 x 15 mm (Medtronic, Santa Rosa, California, USA); LCx: Resolute Integrity 3.0 x 18 mm, kissing balloon inflation, post-dilatation and proximal optimized dilatation with 4.0-mm non-compliant balloon catheter) with IVUS guidance (Figure 1C). IVUS study showed that the minimum stent areas were 11.87 mm2 in the left main trunk, 8.91 mm2 in the LAD, and 6.62 mm2 in the LCx (Figure 4A-C), and no malapposition of the drug-eluting stent (DES). Follow-up angiographic surveillance was performed and showed in-stent restenosis in the proximal LAD, which had functional significance with fractional flow reserve value 0.72 (Figure 1D).
case_images: Coronary angiography in right coronary artery. Right coronary artery had intermediate stenosis with calcification in the vessel wall.
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case_images: TIMI grade 3 with support from an intra-aortic balloon pump. The right coronary artery had intermediate stenosis with calcification in the vessel wall (Figure 2).
case_images: Endovascular intervention for vascular access. (A) Significant stenosis in left common iliac artery. (B) Post-endovascular intervention with SMART stent 9.0 x 60 mm (Cordis, Santa Clara, California, USA).
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case_images: Endovascular intervention for arterial access was also performed because of severe stenosis in the left common iliac artery before the initial PCI (Figure 3).
case_images: Cross-sectional intravascular ultrasound images in culotte bifurcation two-stenting. (A) Distal left main trunk. (B) Proximal left anterior descending artery. (C) Proximal left circumflex artery.
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case_images: Integrity 3.0 x 15 mm (Medtronic, Santa Rosa, California, USA); LCx: Resolute Integrity 3.0 x 18 mm, kissing balloon inflation, post-dilatation and proximal optimized dilatation with 4.0-mm non-compliant balloon catheter) with IVUS guidance (Figure 1C). IVUS study showed that the minimum stent areas were 11.87 mm2 in the left main trunk, 8.91 mm2 in the LAD, and 6.62 mm2 in the LCx (Figure 4A-C), and no malapposition of the drug-eluting stent (DES).
case_images: Non-occlusive mesenteric ischemia detected by contrast-enhanced multidetector computed tomography. These images are showed from head side to foot side (Panel A-C). Angiographic phase did not show an occlusion in superior mesenteric artery and showed impaired filling of intramural vessels and mural thinning (paper-thin wall of intestine) (Panel B). Pneumatosis intestinalis in a large segment of small bowel and hepatic portal venous gas were revealed (Panel A and C).
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case_images: The patient, however, died a few days later in an intensive care unit because of non-occlusive mesenteric ischemia (NOMI), which was found by lactate acidosis on arterial blood gas evaluation and contrast-enhanced computed tomography (Figure 5A-C).