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Percutaneous treatment for in-stent restenosis at the left circumflex artery ostium after kissing stenting in left main bifurcation stenosis
- Operator: Seung-Jung Park, MD
Patient's history
A 67-year old female patient underwent "kissing stenting" with a 3.0x33mm Cypher stent at left anterior descending artery (LAD) and a 2.75x28mm Cypher stent at left circumflex artery (LCX) for left main (LM) bifurcation lesion 6 months ago (Image 1 and Image 2 before procedure; Image 3 and Image 4 after procedure). She was happy with the result and no chest pain occurred during 4 months. However, she has been suffered from recurred effort angina for 2 months before admission.
Baseline angiography
Follow-up angiography was performed and the left coronary angiogram showed in-stent restenosis (ISR) at the ostial LCX (Image 5, Image 6). The in-stent segment of LM-LAD stent was perfectly patent.
Planned strategy
Because the LAD stent was patent, we planned to treat only the LCX ostium with T-stenting technique after crushing the LCX stent.
An 8F sheath was inserted through the right femoral artery and the left coronary was engaged with an 8F JL4 catheter. A 0.014 inch Choice PT wire was inserted into the LCX (Image 7) and a 0.014 inch NEOs wire was inserted into LAD (Image 8). To verify proper positioning of the wires, IVUS was done along the LAD wire. The IVUS showed wrong passage of the LCX wire entering into the proximal end of LCX stent, crossing the overlapped cells of the stents, running in the LAD stent and re-entering into the LCX stent. Therefore, a 0.014 inch Extra-support wire was additionally inserted into the LCX stent using the previous LCX wire as a guide post (Image 9). Then, the first LCX wire was removed and IVUS was repeated along the LAD wire. It showed ideal passage of the LAD and LCX wires. The LCX wire was running parallel with the LAD wire from the LCX ostium to the proximal end of LAD stent (Image 10, Image 11, Image 12, Image 13; Movie 1). After assuring position of the two wires in the LAD and LCX, two 2.5x20mm Maverick balloons were positioned from LM to LCX and from LM to LAD, respectively. At first, LM-LCX was dilated at 14atm (2.83mm) and repeated kissing ballooning was followed at 12atm (2.75mm) with each other (Image 14, Image 15). After one more kissing ballooning, IVUS was done in LAD and LCX consecutively. They showed patent LAD stent and incompletely expanded LCX ostium. A 2.75x13mm Cypher stent was positioned at the ostial LCX and deployed at 10atm (2.62mm) with T-stenting technique (Image 16). Then, kissing ballooning was repeated with a 3.0x20mm Maverick balloon in LAD at 10atm (3.18mm) and the stent balloon in LCX at 20atm (2.95mm)(Image 17). Final angiogram showed good result (Image 18, Image 19). IVUS image from LCX to LM showed well deployed and fully expanded LCX stent (Movie 2).
Wonderful Job, Congratulations! How about the long term outcomes after kissing stent technique with DES from your data? I am sure many operators are interrogative. Thanks. Xu Bo
Paul Lee2004-11-28
The issue is that the 1st LM-LCx stent has to make a 90 degree bend in the initial procedure. This resulted in inadequate stent expansion, as shown in the IVUS (Movie 1) This is probably common, resulting in more restenosis in LCx than LAD.
Young-Hak Kim2004-11-29
We used several stenting techniques in LMCA intervention, such as Kissing stetning, Crush technique, T stenting and Stenting crossing LCX. Overall restenosis rate in LMCA bifurcation PCI was 7%. Among the cases with restenosis, 3 cases had restenosis after kissing stenting at 2 main branch and 1 side branch. As Dr. Lee pointed out, underexpansion at the side branch ostium may be one of important factors of restenosis in bifurcation interventions. To prevent underexpansion, we put two stents sequentially with high pressure dilatation before kissing stenting.
Zheng zhen guo2004-12-13
pre-dialted the restenosis lesion with 2.5/20mm balloon, then implanted a 2.75/13mm stent, how about plaque migration? How about the cutting-balloon or longer stent?
Zhonghan Ni2007-11-02
Without the index procedure IVUS data,attributing the restenosis to underexpansin is only a kind of possibility; Do you think to implant another kind of DES a better choice? such as TAXUS.
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