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Percutaneous Intervention for Left Main Chronic Total Occlusion and Concomitant Right Coronary Artery and Renal Artery Stenosis

- Operator: Zhang Oi, MD

Clinical Presentation

A 60-year old man was admitted due to effort chest pain for 2 months. His coronary risk factors were hypertension, hyperlipidemia, smoking, and chronic renal dysfunction. Baseline ECG showed a ST depression at Lead I, aVL, V2~V6. Echocardiography revealed a normal systolic function without regional wall motion abnormality.

Baseline Coronary Angiogram

1. Left coronary angiogram showed a total occlusion of left main coronary artery (LMCA) ostium with TIMI 0 flow (Figure 1).
2. Right coronary angiogram revealed a significant stenosis at middle and distal portion showing good collateral vessels to LMCA (Figure 2, Figure 3).
3. Renal angiogram showed a severe stenosis of proximal left renal artery (Figure 4).

Procedure

A 7F JL 4.0 guiding catheter was engaged to the LM ostium via right femoral artery, and 6F JR 3.5 diagnostic catheter was placed to provide collateral image of left coronary vessels through left femoral artery. After then, HT Pilot 200 wire was firstly tried and crossed the occlusion segment, reached the D1 branch through the contralateral angiogram (Figure 5). A second guide wire (PT-GRAPHIX, Boston Scientific) was successfully placed into left circumflex artery (LCX) (Figure 6), and a third wire (HT Pilot 150) crossed the left anterior descending artery (LAD). The first wire in the D1 was then removed (Figure 7).

After predilatation (Maverick 2.0 X 20 mm) of LAD and LCX (Figure 8), two Cypher stents were placed into the LCX (2.5 X 23 mm) and LAD (3.0 X 28 mm), respectively (Figure 9) and then deployed with crush technique (Figure 10, Figure 11, Figure 12). Final kissing balloon dilation was performed (LAD: 3.0 X 20 mm Sequent upto 12 atm, LCX: 2.5 X 20 mm Maverick upto 12 atm) (Figure 13, Figure 14). The D1 ostium was finally dilated with a 2.0 X 20 mm balloon at 12 atm (Figure 15). Postprocedural angiogram showed good results (Figure 16).
One week later, the staged intervention for RCA and left renal artery were performed. The Firebird sirolimus-eluting stents (Microport, Shanghai, China) (4.0 X 13 mm, 4.0 X 18 mm) were directly implanted in the distal and middle parts of RCA (Figure 17). A Taxus (5.0 X 12 mm, BostonScientific, USA) stent was directly implanted in left renal artery (Figure 18).

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