DCA and Cypher Stent for Left-Main Bifurcation Stenosis

- Operator : Teguh Santoso

DCA and Cypher Stent for Left-Main Bifurcation Stenosis

- Operator : Teguh Santoso, MD

Case Presentation
A 71 year-old man had complaints of exertional angina pectoris at minimal effort which was progressive since last one month. Diagnostic angiogram was performed in another hospital. He went to 4 cardiologists, and was suggested to undergo urgent surgery, but he declined. His coronary risk factors included hypertension and dyslipidemia. Physical examination was unrevealing. His ejection fraction as determined by echocardiography was 48%.
Baseline Coronary Angiography
The left main had 80% stenosis in its bifurcation. The LAD had an acute take off (shown in different angiographic view) and had 95% ostial stenosis. Distal LAD flow was sluggish (TIMI II). The LCX had 30% stenosis and 75% stenosis in the midsegment (Figure 1). The RCA was normal and provided grade I collaterals to the LAD.
Procedure
An 8 F Zuma guiding catheter was used. A 0.014" BMW guide wire was introduced to the LCX and an iron-man guide wire to the LAD. The procedure was performed without the aid of IVUS and without support of intra-aortic balloon pump. After predilatation, a 2.5/18 mm drug-eluting stent "Cypher" was implanted with good result to fix the stenosis in the mid-LCX (Figure 2). The double-wire technique facilitated the introduction of the 3.0-3.49 mm Flexicut to the LM bifurcation-LAD ostium (Figure 3). After sufficient debulking has been achieved (Figure 4), 2 stents were implanted simultaneously in the T-configuration (3.0/33 mm drug-eluting stent "Cypher" to cover the LM bifurcation and proximal LAD and 3.0/9 mm Be-stent to cover the LCX ostium). The procedure was finalized by postdilating both stents with the kissing balloon technique (3.0/20 mm balloon in the LM-LAD and 3.0/15 mm balloon in the LM-LCX). High pressure inflation was applied to achieve a greater than 3.5 mm diameter in the LM-LAD stent (Figure 5). The result was excellent with no residual stenosis (Figure 6). The patient was put on clopidogrel, aspirin, atenolol and atorvastatin. Three months after the procedure, the patient was completely asymptomatic, his ECG and treadmill exercise stress test was negative. He was scheduled to have his 6 month angiographic follow-up. The utility of drug-eluting stent "Cypher" to treat LM bifurcation stenosis has never been systematically studied. An obvious limitation is the fact that the reference LM diameter is usually > 4 mm and to date the biggest "Cypher" stent diameter available is only 3.0 mm. The advisability of oversizing it using bigger balloon is not yet fully elucidated, but pending for the 6 month angiographic follow-up, at 3 months the patient did not show clinical evidence of restenosis.

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