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Left Main Bifurcation Treatment with Simple Cross-over stenting & Intermediate LAD lesion
- Operator: Seung-Whan Lee, MD
Cilinical history

A 56-year old gentleman was admitted to our hospital due to exertional angina for several months. His coronary risk factors were diabetes and hyperlipidemia. His physical examiniation was normal and cardic enzymes were normal. His ECG and chest X-ray were unremarkable. Echocardiography reveals no regional wall motion abnormality with normal LV systolic function.

Coronary angiographic findings

1) Rt. coronary angiography showed diffuse 30-50% stenosis from proximal to mid portion of right coronary artery (RCA). (Figure 1)
2) Lt. coronary angiography showed significantly tight stenosis in distal left main coronary artery (LMCA) to left anterior descending (LAD) ostium with nearly normal-looking circumflex (LCX) ostium and intermediate lesion in mid-LAD. (Figure 2, Figure 3)

Procedure

A 7 Fr JL4 guiding catheter was engaged in left coronary artery through a right femoral approach. We crossed the 0.014 inch BMW wires into the LCX and LAD sequentially, and then performed intravascular ultrasound (IVUS) evaluation for LAD and LCx ostium. It showed the significant stenosis at the distal LMCA with cross sectional area (CSA) of 4.5mm2, however, LCx ostium appeared quiet normal, and proximal LAD had moderate eccentric atherosclerotic lesion. (Figure 4) Mid-LAD had mild to moderate eccentric plaque and negative remodeling with CSA 3.5 mm2. (Figure 5) In order to evaluate the hemodynamic impact of these lesions, we performed fractional flow reserve (FFR) in LAD. A 0.014” pressure wire was used for the FFR measurement, while hyperemia was induced by intravenous adenosine administration. FFR was 0.82 in the prox-LAD and 0.76 in the mid LAD. (Figure 6) We planned simple cross-over technique from LM to LAD across LCX. The proximal LAD to LMCA was dilated with Black Hawk 3.5/16 mm. Then, a 4.0/23 mm Xience V stent was placed at the proximal LAD to the LMCA at 12 atm. (Figure 7) A high pressure post-dilation was performed with a 4.5/12 mm Fortis balloon at 20 atm. (Figure 8) The final angiogram showed that the procedure was successful without compromising LCX ostium.(Figure 9, Figure 10) Then, we checked FFR for LAD again. FFR was 0.97 in the prox-LAD and 0.88 in the mid LAD. We finished the procedure.

Zh.Q. pang2010-10-07
good case! the simple the best!
Guanghui Chen2010-10-12
The result is successful and perfect. I once againt acknowledge the importance of applying FFR during PCI procedure. The question is that in the setting of FFR unavailable, is it still possible to proper evaluate if mid LAD should be touched or not?
Dr. U.S.Ramjutun2010-10-13
Nice case. Yet we need guts to go for PCI in a patient of 56 years! Maybe because of inhibition or just feeling of insecurity in a centre without on-site surgical team on alert. Please tell us about the risks of plaque shift in this case even in the absence of any ostial lesion in the LCX. What would have been in your opinion the worst case scenario? Thanks a lot
Great case & done in a simple, elegant & very Scientific way!!! my question is ,would you have done it any differently if you had no IVUS or FFR?
Young-Hak Kim2010-10-16
IVUS is routinely performed in our center. FFR is selectively adopted to evaluate the intermediate or side branch stenosis after stenting. Unfortunately, angiography has a poor correlation with FFR in intermediate and side branch evaluation. We need a experience with such modalities. Serious problem due to plaque shift is very uncommon when the LCX os is normal.
dado2010-12-18
DR DADO HAMIKO WHAT YOW WILL DO IF OSTIAL CX SHIFT PLAQUE OCCURED? THANK YOW
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