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LAD Bifurcation Stenosis, Treated with Single Cypher Stent followed by Kissing Balloon Angioplasty

- Operator : Myeong-Ki Hong, MD

Case Presentation
A 64 year-old female had complaints of rest chest pain for 2 months. She received stent PCI at proximal LAD with Palmaz-Schatz stent six years ago. Her follow-up coronary angiogram at 6 months showed in-stent restenosis (ISR) of the proximal LAD stent. Therefore she underwent balloon angioplasty for treatment of ISR. Another stents were inserted at middle LAD and diagonal branch two years ago. Thallium SPECT showed reversible perfusion defect in LAD territory. Echocardiogram showed normal LV function without regional wall motion abnormality.
Baseline Coronary Angiography
The left coronary angiogram showed tight stenosis in the LAD bifurcation with involvement of the ostium of diagonal branch which was located in the gap between the two implanted stents (Figure 1, Figure 2). Previously inserted proximal LAD stents were not significantly narrowed.
Intravascular ultrasound
IVUS examination showed a lot of plaque burden in the bifurcation site and EEM diameter of 4.3 mm (Figure 3). The ostium of the diagonal branch was also narrowed (Figure 4).
Procedure
An 8 Fr sheath was inserted through right femoral artery and the left coronary was engaged with an 8 Fr Judkins left catheter. LAD and diagonal branch were wired with two 0.014 inch Floppy wires. Predilation was performed in the diagonal branch first (Figure 5). Then a 3.0 x 23mm Cypher™ stent was deployed in the middle LAD lesion (Figure 6). Due to the narrowing of the diagonal ostium after stenting (Figure 7), additional balloon dilatation was done in the diagonal branch (Figure 8). Thereafter kissing balloon dilatation was performed twice in LAD and the diagonal branch (Figure 9). Following angiogram showed good stent expansion without significant sustained narrowing of the diagonal branch (Figure 10). Therefore we finished the procedure without additional stenting in the diagonal branch. Final IVUS image showed a good result with a stent area of 6.1 mm2 (Figure 11).
Chiung-Jen Wu2003-06-14
For the IVUS EEL diameter of 4.3 mm, but operator selected a 3x23 mm Cypher stent deployed at lasion site which resulted a final MSA of 6.1 mm2 (relatively small for > 3 mm vessel). Although in drug eluting stent era, optimal MSA nowadays is not an important for ISR (minimal in-stent neointimal regrow), but in SIRIUS & TAXUS-II substudy, smaller reference vessel still had a higher chance of ISR, we need more data to support that "bigger the better" is not necessory in DES era ?
Seung-Jung Park2003-06-16
Hi ! Dr.Wu. How are you ? When we chose the Cypher 3.0 mm size stent, we usually applied high pressure inflation upto 20 atm which would 3.2 mm in diameter. I agree we need more data. However, based on the IVUS data from SIRIUS study, the optimal MSA was around 5 mm2 in the group of No-restenosis. That is reason why we are comfortable with relatively(compare to the BMS era) smaller stent cross sectional area.
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