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Multiple and long overlapping stenting with drug-eluting stents ("full metal jackets") for very long coronary disease

- Operator: Cheol Whan Lee, MD

Clinical Presentation

A 75 year old man was admitted with resting chest pain and dyspnea for 1 month. He experienced acute myocardial infarction 15 years ago. He underwent balloon angioplasty at proximal left anterior descending (LAD) artery and diagonal branch 10 years ago. His coronary risk factors were diabetes and smoking. Echocardiography showed an akinesia of LAD territory and near normal systolic function (LVEF = 54%). Thallium scan revealed reversible perfusion defects in LAD and RCA territory.

Baseline Coronary Angiography

1. Left coronary angiogram showed diffuse long lesions in distal left circumflex artery (LCX) and ostium to middle LAD (Figure 1, Figure 2, Figure 3).
2. Right coronary angiography showed a proximal total obstruction with TIMI flow 1 (Figure 4, Figure 5).

Procedure

After engaging of Judkin 4 guiding catheter, a 0.014 inch Soft wire was introduced into the LCX. After pre-dilation using a Blackhawk balloon (2.5mm x 20mm up to 2.5mm at 6atm), single long Cypher stent was implanted (2.75mm x 33 mm up to 2.96mm at 16atm) (Figure 6, Figure 7). And then, a 0.014 inch Soft wire was positioned and pre-dilated with a Blackhawk balloon in the LAD (2.5mm x 20mm up to 2.5mm at 6atm) (Figure 8). After Cypher stenting (3.0mm x 33mm up to 3.31mm at 20atm) with additional high pressure balloon dilatation (Sprinter balloon 3.5mm x 15mm up to 3.62mm at 10atm) at middle LAD (Figure 9), an additional Cypher stent (3.5mm x 18mm up to 3.31mm at 20atm) with additional high pressure balloon dilatation (Sprinter 3.5mm x 15mm up to 3.9mm at 16atm) was deployed to cover the ostial LAD (Figure 10). Angiogram showed a good result without residual narrowing (Figure 11, Figure 12).

After engaging of AL 2 guiding catheter, a 0.014 inch Pilot wire using the OTW system was introduced into the RCA. After pre-dilation using an OTW Maverick balloon (1.5mm x 20mm up to 1.59mm at 10atm), angiogram showed long lesion involving proximal to distal RCA (Figure 13). Following pre-dilation using a Blackhawk balloon (2.5mm x 20mm up to 2.73mm at 13atm), three Cypher stents (2.75mm x 33mm in distal RCA, 3.0mm x 33mm in middle RCA, and 3.5mm x 28mm in ostium to proximal RCA ) were implanted (Figure 14, Figure 15, Figure 16). Post-procedural angiogram showed a good patency without residual narrowing (Figure 17, Figure 18). Post-procedural CK-MB was normal and this patient was discharged without any in-hospital events. A 6-months follow-up angiogram showed patent all stents without instent restenosis (Figure 19, Figure 20, Figure 21, Figure 22, Figure 23).

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