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Cyper Stent Implantation for Ostial Left Anterior Descending Artery Stenosis with Intravascular Ultrasound Guidance
- Operator: Myeong-Ki Hong, MD
Case presentation

A 57 year-old male was admitted with effort chest pain for 5 months. Coronary risk factors included smoking and hypertension. His baseline ECG showed pathologic Q wave in II, III, aVF. Echocardiography revealed normal LV function with focal akinesia of basal inferior and basal septal wall and Thallium SPECT showed abnormal slow thallium washout suggesting multivessel coronary artery disease.

Baseline coronary angiography

1. Right coronary angiogram showed chronic total obstruction at middle portion (Figure 1). At first, PCI for this CTO lesion was attempted but failed due to guidewire passage failure despite using a small tracking balloon catheter over 0.014 inch Shinobi wire.
2. Left coronary angiogram showed significant narrowing of LAD ostium (Figure 2, Figure 3). Distal left main (LM) and LCX ostium seemed to be angiographically intact, which allowed us to try precise ostial stenting without crossing-over LCX ostium and extending to distal LM.

Procedure
After right femoral artery was punctured, an 8F Judkins guiding catheter was positioned at the origin of LM. After the advancement of 0.014 Floppy guidewire into LAD, Intravascular ultrasound (IVUS) was performed to identify the extent and degree of plaque burden at LAD ostium, LCX ostium and distal LM. Pre-stenting IVUS showed significant narrowing and abundant plaque burden confined to LAD ostium (Figure 4; EEM CSA 14.38mm2, Lumen CSA 2.86mm2, Plaque burden 80%) without extending to distal LM (Figure 5; EEM CSA 17.89mm2, Lumen CSA 16.28mm2, Plaque burden 10%) . After confirming intactness of the distal LM and LCX ostium by using of IVUS, we decided to perform accurate single stenting at LAD ostium without jeopardizing LM and LCX branch. Without pre-dilation, a 3.5x18mm Cypher stent was positioned at the targeted LAD ostial lesion ensuring that the proximal marker of stent should be situated exactly in the LAD ostium and not protrude proximally to the carina of the bifurcation (Figure 6) and deployed at 16 atm (3.76mm) (Figure 7). For stent optimization, adjunctive high pressure dilatation was performed with a Quantum balloon 3.5 (9mm) upto to 3.7mm at 20 atm (Figure 8). Final angiogram showed an excellent result without patency-compromising stent jail or plaque shifting into LCX ostium and distal LM (Figure 9).
Dr Y K D Bhatta2005-01-17
why did you use 8 french guiding?
Young-Hak Kim2005-01-20
Actually, we often start the procedure with an 8 Fr guiding catheter in distal left main intervention. The large sized guiding catheter may be more useful in complex bifurcatio stenting.
fernando kozak2005-05-28
fernando kozak2005-05-28
Why didn t you use intravascular ultrasound post-stent?
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