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Multivessel PCI with Cypher Stents and Bare Metal Stents for Lesions with Big Reference Vessel and Vulnerable Plaque
- Operator : Seung-Jung Park, MD
Case Presentation
The patient was 42 year-old male. He presented with a recent onset (2-3 days) of resting chest pain. He had hypertension, hypercholesterolemia, and hypertension as coronary risk factors. EKG revealed deep T inversion on V1-V6. Cardiac enzymes including CK-MB and Troponin I were elevated at admission. Echocardiography showed normal LV ejection fraction of 59% with regional wall motion abnormalities in LAD and RCA territories.
Baseline coronary angiography
1. Coronary angiogram showed discrete proximal LAD stenosis and diffuse RCA stenosis (Figure 1, Figure 2 and Figure 3).

2. LCX was normal.

Planned strategy
We intended to perform stenting in the proximal LAD lesion and planned to select strategy for RCA lesions after IVUS examination.
Procedure
An 8F sheath was inserted through the right femoral artery and the left coronary was engaged with an 8F Zuma (JL4) catheter. A 0.014" guidewire was placed into LAD. IVUS image through the guidewire showed tight stenosis in proximal LAD (Figure 4). Predilatation was performed with a 3.0 x 20mm X1S balloon at nominal pressure (Figure 5). Following angiogram revealed significant residual stenosis with haziness at proximal LAD (Figure 6). And then, a 3.0 x 23mm Cypher stent was implanted in proximal LAD at 20 atm (Figure 7). Following angiogram showed good result (Figure 8). However, IVUS image showed stent inapposition in the proximal portion of the stent (Figure 9), and additional high pressure balloon dilatation was performed with a 3.5 x15 mm U-pass balloon at 14 atm. Until now, additional high pressure balloon dilatation is inevitable for stent optimization because Cypher stents > 3 mm are not available in Korea. Final coronary angiogram (Figure 10) and IVUS image showed good results (Figure 11).
The right coronary was engaged with a 7F JL4 catheter. A 0.014" Choice PT guidewire was placed into RCA. IVUS image through the guidewire showed diffuse stenosis in proximal(Figure 12) and middle RCA (Figure 13) and tight stenosis in distal RCA (Figure 14). The external elastic membrane (EEM) cross sectional area (CSA) of proximal RCA, middle RCA, and distal RCA were 18.5 mm2, 17.8 mm2, and 14.5 mm2, respectively. Therefore we decided to implant large sized bare metal stents in proximal and middle RCA lesions and a Cypher stent in distal RCA lesion. At this time we considered 2 points; (1) we do not have large sized Cypher stents suitable for proximal RCA lesion and (2) the restenosis rate of bare metal stent for proximal RCA with postprocedural MLD 4.0 mm was expected below 10%. Then predilatation was performed with a 3.0 x 20 mm Black Hawk balloon from proximal to distal RCA lesions (Figure 15). Then a 5.0 x 32 mm Express stent was implanted in middle RCA lesion first at 12 atm. Following angiogram (Figure 16) and IVUS image (Figure 17) showed good result with lumen CSA of 21.8 mm2. Then distal and proximal RCA lesions were stented with a 3.0 x 23 mm Cypher stent at 20 atm (Figure 18), and a 5.0 x 24 mm Express stent (Figure 19), sequentially. Proximal and middle RCA was dilated further with the same stent balloon upto 14 atm (Figure 20). Final angiogram (Figure 21) and IVUS image (Figure 22) showed good results without inappositon of stents. However, the middle RCA between two bare metal stents appeared to be narrowed and IVUS image showed the lipid core at 3 O'clock (Figure 23). Although the unstented middle RCA lesion had the vulnerable plaque and was mildly narrowed by IVUS image, we ended the procedure because the benefit of stenting with drug eluting stent for lesion with vulnerable plaque was not proved.
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