Left Main Lesion Treated with Cross-Over Technique

- Operator : Seung-Jung Park

Left Main Lesion Treated with Cross-Over Technique
- Operator: Seung-Jung Park, MD
Clinical presentation

A 67-year old man visited our clinic for the second opinion about possibility of coronary intervention. He suffered effort chest pain for 1 month and was diagnosed of left main with 3 vessel disease at other hospital. His coronary risk factors were hypertension and dyslipidemia. His baseline ECG was normal. Echocardiography showed normal LV systolic function (EF = 68%). And Thallium spect revealed the large reversible defect in LAD territory.

Baseline coronary angiogram

1. Left coronary angiogram showed distal LM significant stenosis with ostium to proximal LAD with heavy calcium. And LCX showed diffuse stenosis but diminutive. ( Movie 1, Movie 2) 2. Right coronary angiogram showed significant stenosis at proximal to mid RCA. ( Movie 3)

Procedure

An 8F sheath was inserted through right femoral artery, which was very tortuous(Figure 1),and was exchanged to 24cm long sheath. And the left coronary ostium was engaged with an 8F XB catheter with 3.5cm curve. 0.014 inch BMW guidewire was inserted into the LAD and another BMW wire was tried to insert into diagonal branch but failed. Pre-ballooning with Sprinter 2.5 X 15mm, Dura Star 2.5 X 15mm were performed sequentially up to 2.84 mm with 18 atm at proximal LAD.(Figure 2) And Cutting balloon 3.0 X 10mm was also applied twice at proximal LAD. We tried to deliver and insert stents but failed due to severe tortuous femoral artery (Figure 3). And then we changed the guidwire to 0.014 inch Flexicut wire 300cm with microcatheter. But we failed to deliver stent and then straightened femoral artery with 0.035 inch Stiff wire and succeeded in delivering stent. From mid LAD to LM, we deployed the Xience V Stent 3.5 X 23mm, 3.5 X 23mm, and 4.0 X 23mm sequentially. (Figure 4). Post-stent high pressure ballooning with Fortis 4.0 X 18mm also applied without complication (Figure 5). Final angiogram showed well-expanded stents without residual narrowing or jail of side branch (Figure 6). After pressure wire (RADI) insertion into RCA, we checked FFR. Baseline FFR was 1. Then we induced hyperemia by intracoronary adenosine injection. After induction of hyperemia, FFR was 0.92. Previously performed thallium spect did showed no abnormal perfusion defect in RCA territory. So, instead of performing PCI, we decided to treat RCA medically.

Comments

  • Zhonghan Ni 2010-05-08 It looks like an ulcerated lesion at the pro-LAD,doesn't it?

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