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LM Shaft Disease and Calcified Proximal LAD Disease
- Operators: Seung-Jung Park, Roxana Mehran, Seong-Wook Park
Clinical presentation
A 76-year old woman was suffered from effort-related chest pain for 1 month. So, She visited other hospital and got coronary angiography. That coronary angiogram showed left main coronary artery disease. So, she referred from that hospital for management of this lesion. Her coronary risk factor was hypertension. Baseline ECG showed no ST segment change. Echocardiography revealed no regional wall motion abnormality and normal LV systolic function. Other noninvasive stress testings were not done.
Baseline coronary angiogram

1. Left coronary angiogram showed 80% narrowing of LM shaft, diffuse 80% narrowing with calcification of pLAD (Figure 1, Figure 2).
2. Right coronary angiogram showed diffuse intermediate lesions(not shown).

Procedure
A 8Fr sheath was inserted into the right femoral artery, and the left coronary ostium was engaged with a 8Fr JL guiding catheter with 5.0cm curve. A 0.014 inch BMW wire was inserted into the LAD. After predilation of LM shaft with Black Hawk 2.5 X 20 mm, IVUS study was done about LM to LAD. IVUS findings revealed heavy plaque burden with encircling calcification in the proximal LAD (Figure 3) and heavy plaque burden in the LM shaft (Figure 4). Initially we performed predilation with safecut NM 2.5 X 20mm at calcified pLAD lesion (Figure 5, Figure 6). And then LM shaft and pLAD lesion was predilated with 2.5 X 20mm Maverick balloon and 3.0 X 20mm Maverick balloon sequentially. But IVUS catheter cannot inserted into the LAD. So additional predilation was performed with 3.0 X 12mm Quantum (Figure 7, Figure 8). IVUS study was done again. We planned to insert the Cypher select 3.0 X 23mm stent. But stent was not advanced into the LAD and another 0.014 inch BMW wire was inserted into the LAD for double wire technique. And then additional predilation was performed with 3.0 X 20mm Maverick balloon. Thereafter Cypher select 3.0 X 23mm stent and Cypher select 3.5 X 33mm stent were deployed at ostial LM to pLAD sequentially.(Figure 9). IVUS study was done again. LM stent was underexpanded (Figure 10) and additional high pressure balloon dilation with 4.5 X 12mm Quantum was performed (Figure 11). And then IVUS study was done. IVUS findings showed good position and well expansion at ostial LM to pLAD (Figure 12). Final left angiogram showed that the procedure was successful (Figure 13, Figure 14).
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