Left Main Bifurcation Intervention with Debulking Atherectomy and Cypher Stent Implantation

- Operator : Seung-Jung Park

Left Main Bifurcation Intervention with Debulking Atherectomy and Cypher Stent Implantation
- Operator: Seung-Jung Park, MD

Clinical presentation

A 67-year old man was admitted due to unstable angina for 1 month. His coronary risk factors were hypertension and smoking. Echocardiography showed normal ejection fraction without wall motion abnormality.

Baseline angiography

Left coronary angiogram showed distal left main coronary artery (LMCA) bifurcation lesion with the involvement of ostia of left anterior descending artery (LAD) and left circumflex artery (LCX) (Figure 1, Figure 2). Right coronary angiogram was normal.

Procedure

An 8F sheath was inserted through the right femoral artery and the left coronary was engaged with an 8F EBU 3.5. At first, left main to LCX was wired with 0.014" Floppy wire (Figure 3). Then, wiring of left main to LAD was tried with 0.014" Choice PT, Shinobi and Soft wire. But, wire passage to LAD was not easily performed. So, the 7Fr DCA device (3.5-4.0mm) was advanced into the proximal LCX and three cuts were done in order to facilitate wiring into the LAD. And then, successful wire advancement was performed into the LAD. After predilation with a Maverick 2.5mm x 20mm upto 2.5mm (8atm), LMCA and LAD ostium was stented with a 3.5 mm x 23 mm Cypher stent at 18 atm crossing the LCX ostium (Figure 4). Following angiogram showed a compromise of the LCX ostium (Figure 5). Thus, the LCX ostium was dilated with a 3.0mm x 20mm Sprinter balloon at 14 atm and followed by simultaneous kissing balloon dilatation with a 3.0mm x 20 mm Maverick balloon at 10 atm in LMCA-LAD and a 3.0mm x 20mm Sprinter balloon at 14 atm in LMCA-LCX (Figure 6). Final angiogram showed a good result (Figure 7, Figure 8).

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Comments

  • Alberto Hendler 2005-11-20 In my opinion if your starting point was that the ostium of the LCX was involved, the best approach would be the SKS, or simultaneous kissing stents. A. Hendler MD
  • Seung-Jung Park 2005-11-21 I agree your suggestion. However, IVUS finding showed not so much plaque burden on LCX ostium and the reference vessel diameter of LCX was big enough (more than 4.0mm) to avoid stenting pprocedure. Based on the the data, two kissing stent technique has relatively high angiographic restenosis rate compare tnan that of sigle stent cross over. Thanks
  • Joy M. Thomas 2005-11-24 Very good strategy. Debulking the bifurcation has made access to LAD easier.
  • Dr.Pramod Jaiswal 2005-11-25 Excellent case and great result. Can rotablator also give resonable debulking in such a situation?
  • umamahesh C Rangasetty 2005-11-27 What is the mechanism by which debulking of the LCX resulted in successful wiring of the LAD?
  • Young-Hak Kim 2005-11-29 Because the plaque at the ostial LCX was bent against the ostial LAD. So, debulking of the plaque facilitated wiring into the LAD. Moreover, we hope that DCA would be beneficial in preventing restenosis of the ostial LCX and improving the technical feasibility of repeat intervention.
  • SanjaySrivatsa 2005-12-14 dr park, I am interested to know the data avilable for SKS versus, single stent with ptca rescue of lcx versus crush stenting-either conventional or revrese crush on the inside for distal lmain bifurcation--can you point me to the data? Also for crush cases do you prefer to crush the LCX stent or crush the lad stent given that access to lad is a straight shot and easier for manipulation but potentially more critical if access to lad cannot be re-established. as always your site is very interesting

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