Slides
Left Main Trifurcation, Treated by Three Cypher Stents,
- Operator : Antonio Colombo
| Left Main Trifurcation, Treated by Three Cypher Stents, "Stent-Crush" by Dr. A. Colombo |
| - Operator : Antonio Colombo, MD |
| Case Presentation |
| The patient was 51 year-old male. He presented with a recent onset (2-3 days) of resting chest pain. He had a hypertension as a coronary risk factor. EKG revealed ST change on anterior leads. Echocardiography showed normal LV ejection fraction of 56% without regional wall motion abnormality. |
| Baseline coronary angiography |
| 1. Coronary angiogram showed tight distal left main
stenosis including trifurcation of RI, LAD, and LCX, and tight stenosis
of mid LAD lesion (Figure
1, Figure
2).
2. LCX and RCA were normal. |
| Procedure |
| A 9F sheath was inserted through right femoral artery and the left coronary was engaged with a 9F EBU catheter. Three 0.014 inch guidewires were placed into LAD, LCX, and RI branch respectively (Figure 3). Once it was determined that the guidewire was in the distal vessel, ReoPro was administered and continued for 12 hours. Predilatation from left main to RI branch was performed with a 2.5x20mm balloon at nominal pressure (Figure 4). And then ostial LCX was dilated with 2.5x20mm balloon at nominal pressure (Figure 5). However, LCX ostium remained narrowed. Thus additional predilatation was done with 2.75x10 mm cutting balloon at 10 atm (Figure 6). Following angiogram revealed moderate residual stenosis with haziness at ostial LCX. Three stents on their delivery balloon parked in the appropriate positions. In case of treatment for trifurcation, important technical approach is that the stent going to the main branch is inflated last and the one going to the smallest or less important branch is inflated first. Therefore, we were first to treat RI branch with Cypher stent 2.5x18mm at 14 atm (Figure 7) (this branch is smaller and shorter compared to LAD, LCX). After removing the wire in RI, the stent (Cypher 3.0 x18mm at 16 atm) into the LCX (Figure 8) and the stent (Cypher 3.0x18mm at 20 atm) in the left main toward the LAD were sequentially deployed (Figure 9). It is important that following each deployment, the balloon, as well as the wire, are both removed from the specific coronary artery otherwise they will be trapped. Final angiogram showed optimal angiographic results in multiple projections (Figure 10, Figure 11). Remained mid LAD lesion was also treated with Cypher stent 3.0x15mm at nominal pressure and distal LCX lesion was treated with optimal balloon angioplasty. |
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