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Stent Damage Attributable to IVUS Catheter in Promus Element Stent After Successful Crushing Technique for the Treatment of Distal LM disease
- Operator: Young-Hak Kim, MD
A 79 year-old woman was admitted with an ongoing effort chest pain. Her coronary risk factors were dyslipidemia and hypertension. As a non-invasive function tests were not done. The echocardiography showed akinesia of LAD territory with normal LV systolic function (EF=63%).
Baseline coronary angiogram
1. A left coronary angiogram showed diffuse 70% stenosis of distal LM, diffuse 80% stenosis with calcification of proximal to mid LAD and diffuse 80% stenosis of proximal LCX. ( Movie 1, Movie 2)
2. A right coronary angiogram showed diffuse intermediate lesions (Figure 1).
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8F JL catheter with 4.0 cm curve. The 0.014-inch 190cm BMW gudiewire was inserted into the LCX. The 0.014-inch 180cm Fielder FC guidewire was inserted into LAD. Proximal to mid LAD was predilated with 2.50 x 20mm TREK balloon and proximal LAD to LM was predilated with 3.0 x 20mm Voyager NC balloon. Thereafter, we pre-dilated proximal LCX using 2.5 X 20mm TREK balloon. A PROMUS Element 3.0 x 38 mm Stent was successfully deployed at proximal to mid LAD (Figure 2). A PROMUS Element 3.5 x 16mm Stent was successfully deployed at proximal LCX (Figure 3). We performed crushing with a PROMUS 4.0 x 28 mm at dLM to pLAD. ( Movie 3) Additional kissing ballooning was performed by using a Fortis 4.0 x 18mm at LM-proximal LAD and a Voyager NC 3.0 x 20mm at proximal LCX ( Movie 4). The angiographic result was satisfactory with a negative angiographic diameter stenosis ( Movie 5). In order to check the adequacy of the stent expansion, a 3.2 Fr IVUS catheter (Boston Scientific/SCIMED, Minneapolis, MN) was inserted at LM to LAD, but during the IVUS exam, IVUS was not able to be pulled back, as the IVUS sleeve jammed in the mid part of the stent. After several attempts, consecutive fluoroscopy showed a disarrangement of the stent strut ( Movie 6, Figure 5). The patient remained asymptomatic and the ECG did not change. One more balloon dilatation by using Fortis 4.0 x 18mm was then performed at a higher pressure (20atm), but the orientation of the stent struts remained disarranged ( Movie 7). So, we decided additional stenting at disarranged site. A Promus Element 3.5 x 12mm stent was inserted (Figure 4). No further IVUS examination of the stent was attempted. Final left angiogram showed that the procedure was successful ( Movie 8).
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