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LM Bifurcation and ISR Lesion Intervention with Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 96-year-old female patient was admitted for dyspnea on exertion. She had previous PCI history due to acute MI, in which Cypher stents were implanted to prox-to-mid LAD and proximal LCX, respectively. Physical examination, a simple chest radiograph showed pulmonary congestion and were unremarkable. Echocardiogram showed mild LV dysfunction with akinetic wall motion of LCX territory.
Baseline Coronary Angiogram & IVUS
  1. The left coronary angiogram showed discrete lesion at distal LM and pLCX ostium. Prox to mid LAD with the previous stent had diffuse in-stent re-stenosis (ISR) lesion, of which FFR showed decrement of pressure (0.79 to 0.62, baseline to hyperemic state, respectively). In the distal part of LM lesion, FFR (at hyperemia) was 0.70, so ischemia was assumed to occur mainly due to LM lesion ( Movie 1, Movie 2).
  2. The right coronary angiogram showed diffuse lesion with chronic total occlusion at the mRCA portion ( Movie 3).
Procedure
A 7 Fr femoral sheath (Terumo) was inserted through the right femoral artery and left coronary artery was engaged with a 7 Fr JL 4 guiding catheter. A 0.014-inch BMW 190 cm wire and a 0.014-inch Sion 180cm wire were inserted into LAD and LCX, respectively. Before the intervention, IVUS was used to identify lesion characteristics of LAD and LCX, in which diffuse LM disease was identified with tight ostial stenosis of LCX and previous Cypher stent of LCX protruding to LM (Figure 1, Figure 2 with LAD, LCI IVUS, respectively). Sapphire NC balloon sized 3.5 x 15 mm was used to dilate stenotic lesion of LM-proximal LCX ( Movie 4). After dilation of LCX, LM-pLAD in-stent was also dilated to crush previous Cypher stent of pLCX using Raiden 3 balloon sized 4.0 x 15mm ( Movie 5). XIENCE Sierra stent sized 4.0 x 23 mm was deployed at denovo LM lesion and pre-stented pLAD ( Movie 6). After checking IVUS, POT and kissing balloon were applied using Raiden 3 upto 8 atm (3.83) and Sapphire NC balloon upto 10 atm (3.44) in LM-pLAD, pLCX, respectively ( Movie 7). The final angiogram showed no stenotic lesion and good flow, and IVUS showed no immediate complication ( Movie 8).
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