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LM and LAD Bifurcation Intervention with Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 72-year-old male was admitted for effort chest pain. Physical examination and Chest X-ray were no remarkable. Echocardiogram showed moderate LV dysfunction (EF 40%) with inferolateral and apical wall motion abnormality.
Baseline Coronary Angiogram & IVUS
  1. The left coronary angiogram showed tubular 60-70% stenotic lesion at distal LM. Prox to mid LAD, prox LCX and high diagonal artery had diffuse 80% stenotic lesion ( Movie 1, Movie 2).
  2. The right coronary angiogram showed mild coronary artery disease ( Movie 3).
Procedure
A 8Fr femoral sheath (Terumo) was inserted through the right femoral artery and left coronary artery was engaged with a 8 Fr JL 4 guiding catheter. A 0.014-inch BMW 190 cm wire and a 0.014-inch BMW 190cm wire were inserted into LAD and LCX, respectively. Before the intervention, IVUS was used to identify lesion characteristics of LM-LAD, LCX and Diagonal artery, in which diffuse 80% stenosis LM disease, diffuse stenosis LCx disease and tight ostial stenosis of Diagonal artery were identified. (Figure 1, Figure 2, Figure 3 with LAD, LCX, Diagonal artery IVUS, respectively). Euphora balloon sized 2.5 x 20 mm was used to dilate stenotic lesion of proximal to distal LCX ( Movie 4). After dilation of LCX, XIENCE Sierra stent sized 3.0 x 38 mm was deployed at distal LCX ( Movie 5). Euphora balloon sized 2.5 x 20 mm was used to dilate stenotic lesion of diagonal artery. After dilation of diagonal artery, XIENCE Sierra stent sized 2.5 x 23 mm was deployed at diagonal artery ( Movie 6). Sapphire NC balloon sized 3.5 x 18 mm was used to dilate stenotic lesion of proximal to mid LAD ( Movie 7). XIENCE Sierra stent sized 4.0 x 18 mm was deployed at LM-pLAD and crushed the proximal LCX stent, Xience 3.5 x 15mm ( Movie 8). XIENCE Sierra stent sized 3.5 x 15 mm was deployed at proximal LCX ( Movie 9). NC ROVL 4.0 x 20 mm was inflated at proximal LAD to crush the diagonal stent, Xience 2.5 x 23 mm ( Movie 10). After rewiring Diagonal artery, Tazuna 1.5 x 15 mm was inflated at diagonal stent, Xience Sierra 2.5 x 23 mm ( Movie 11). After rewiring LCX artery, Tazuna 1.5 x 15 mm was inflated at LCX stent, Xience Sierra 3.5 x 15 mm ( Movie 12). Kissing balloons which are NC ROVL 4.0 x 20 mm at primxal LAD, Sapphire NC 3.5 x 18 mm at proximal LCX and NC Emerge 2.5 x 15 mm at diagonal artery were inflated upto 8 atm (3.90) at LAD, 10 atm (3.44) at LCX and 10 atm (2.40) at diagonal atery simultaneously ( Movie 13). Final angiogram showed successful revascularization of LAD, LCX and Diagonal artery ( Movie 14).
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