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Decision Making Using with Fractional Flow Reserve after LAD Bifurcation ISR Lesion Treated with Simple Cross-Over Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 66 year-old man was admitted with effort chest pain for 3 days. 10-years ago he had underwent PCI on LAD bifurcation lesion (BMS) with kissing ballooning of diagonal branch. His coronary risk factors were hypertension, diabetes mellitus, and ex-smoker. The physical examination was normal. The ECG were unremarkable. The cardiac marker was elevated and the echocardiography showed RWMA in LAD territory with preserved EF (64%).
Baseline Coronary Angiography
The left coronary angiogram showed subtotally occluded LAD bifurcation with TIMI grade 2 flow ( Movie 1, Movie 2). The right coronary angiogram showed minimal disease.
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 3.5 catheter with side hole. Three 0.014 inch BMW wires were inserted into the LAD, and diagonal branch. We examed lesions with IVUS to make a decision. IVUS examination revealed relatively normal diagonal ostium (Figure 1). So, we intended to treat the lesions with simple cross-over technique. Predilatation was performed with a 2.5 x 20mm Maverick balloon at pLAD (Figure 2). After predilatation, Resolute Integrity stent (3.5x26mm) were implanted at dLM to pLAD (Figure 3). And then, postdilatation using a 3.5 x 15mm Empira NC balloon and 4.0 x 8mm Quantum balloon was performed. The following angiogram showed well-expanded stents, but stenosis of diagonal ostium was observed ( Movie 3). We checked diagonal FFR, which was 0.89. Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).
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