Unprotected Left Main Percutaneous Coronary Intervention in a 108-Year-Old Patient
A 108-year-old man was referred with ongoing chest pain on minimal or no exertion (Canadian Cardiovascular Society class III-IV) despite optimum medical therapy. He was an ex-smoker, hypertensive, but non-diabetic, and had chronic kidney disease, Parkinsonism and below-knee amputation of the left leg due to a previous road-traffic accident. His pulse was 80/min, blood pressure 140/90 mm Hg, and the lung bases were clear. His resting electrocardiogram (ECG) showed sinus rhythm, ST depression and T inversion in leads V 5, V 6, I and aVL, and ST elevation in aVR (); echocardiography revealed distal septal and basal inferior left ventricular wall hypokinesia with a left ventricular ejection fraction of 45-50%. Blood counts and biochemistry including the sugar and lipid profile were normal. Serum creatinine was 1.6 mg/dL, and the glomerular filtration rate was 40.8 mL/min. CAG was done because of ongoing chest pain; there was triple vessel disease with involvement of the left main coronary artery (LMCA); there was 75% stenosis in the distal LMCA, 95% stenosis in the proximal segment and 75% stenosis in the mid segments of the left anterior descending (LAD) artery, 75% osteo-proximal and 90% distal stenosis in the left circumflex (LCX) artery, and total occlusion of the right coronary artery from the origin (). The calculated Euroscore was 20, and the SYNTAX score 37. Coronary artery bypass graft (CABG) surgery was advised, but the surgeons declined to perform it. So, percutaneous transluminal coronary angioplasty and stenting were done for the LMCA and LAD lesions; LMCA was hooked by a JL 3.5, 7 Fr guide catheter, and the LAD lesion was navigated with a hydrophilic guidewire (BMW guidewire, Abbott Vascular, Santa Clara, CA, USA), while another hydrophilic guidewire (Runthrough™ NS Coronary Guidewire, Terumo Medical Corporation, Tokyo, Japan) was kept in the distal LCX. Predilatation was done with a 2.5×12 mm noncompliant balloon (NC Sprinter RX Noncompliant Balloon Dilatation Catheter, Medtronic Vascular, Minneapolis, MN, USA) at 12-14 atm. A 2.75×36 mm biodegradable polymer drug-eluting stent (DES) (BioMatrix Flex, Biosensors International, Bulach, Switzerland) was deployed over the proximal to mid LAD lesion at 14 atm for 20 seconds. Another 3.5×33 mm BioMatrix Flex stent (Biosensors International) was deployed over the left main to proximal LAD lesion at 14 atm for 20 seconds, and overlapped with the previous stent. Post-dilatation was done with a 3.5×12 mm Quantum balloon (Quantum™ Maverick® Balloon Catheters, Boston Scientific Corp.) that was deployed at up to 22 atm. The LCX wire was re-crossed, and the ostial lesion was dilated with a 2.5×12 mm noncompliant balloon (NC Sprinter RX Noncompliant Balloon Dilatation Catheter, Medtronic Vascular) at 12 atm. Finally, kissing balloon dilatation was done with LAD (3.5×12 mm Quantum) and LCX (2.5×12 mm Sprinter) balloons at 18 and 12 atm respectively. Thrombolysis in Myocardial Infarction III flow was established (). A temporary pacemaker and intra-aortic balloon pump, and provisions for an emergency CABG were kept ready. The immediate post-procedural period was uneventful. The patient was free of chest pain; ECG changes became normal (), echocardiography revealed improvement in regional left ventricular wall motion, with an ejection fraction of 58%, and the troponin I was negative (0.118 ng/mL). However, on the first post-procedural day, the patient developed an acute confusional state and abdominal distension. A CT scan of the brain and an ultrasonogram of the abdomen revealed no significant abnormalities. Blood biochemistry including the serum creatinine was normal. On day 2, the confusional state and abdominal distension improved with conservative measures, and on the third post-procedure day, the patient was oriented and able to converse well. He was discharged with aspirin 75 mg and clopidogrel 75 mg daily. During the subsequent 3 months' follow-up, the patient remained free of symptoms.