Case 208: Manual of PCI - A different cause of ST elevation

An elderly woman with prior CABG and porcelain aorta presented with unstable angina. Coronary angiography showed 99% ostial left main stenosis along with severe disease in the mid LAD (her LIMA to LAD was occluded). The SVGs to the PDA and the OM branch were patent. She was turned down for redo CABG and referred for complex PCI. We were unable to insert an Impella CP device due to severe PAD. The left main was engaged with an 8 French EBU guide with intermittent disengagement to avoid pressure dampening. After predilatation and intravascular lithotripsy the mid LAD and the left main were successfully stented. FFR, however, was 0.71. An additional stent was placed in the proximal LAD but the FFR remained low at 0.83. Another stent was placed in the mid LAD causing a coronary perforation. Delivery of a PK Papyrus covered stent was challenging. Ping pong guides could not be used because the left main stent was protruding into the aorta. Eventually a Guideliner Coast was inchwormed with a 3.0 mm balloon, followed by successful delivery of the covered stent and sealing of the perforation. However, the patient continued to have significant ST segment elevation. Chest CT showed a small blood collection next to the LAD stent. The ST elevation resolved the following day and the patient had an uneventful recovery.