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FFR-guided PCI for diffuse, tandem lesion in prox-to distal RCA
- Operator: Seung-Jung Park, MD
Cilinical history

A 63-year-old hypertensive, dyslipidemic woman was admitted to our hospital due to exertional angina for 3 months. Her physical examiniation was normal and cardic enzymes were normal. ECG and chest X-ray were unremarkable except bradycardia of 55 BPM. Echocardiography revealed apical hypokinesia with LVEF ~55%. Thallium SPECT showed reversible large sized perfusion defect in inferior and anterior wall.

Coronary angiographic findings

1) Rt. coronary angiography showed diffuse, tandem-looked, 70-80% stenosis at prox to mid segment and diffuse 70-90% stenosis at mid to distal segment of right coronary artery (RCA).(Figure 1, Figure 2)
2) Lt. coronary angiography showed significant stenosis at proximal to mid LAD involving proximal bifurcation site and diffuse stenosis in LCX.(Figure 3, Figure 4)

Procedure

First, RCA was engaged with a 7Fr AR2 guiding catheter with side holes and was crossed with a 0.014” BMW guidewire. We advanced a 0.014” pressure wire into the RCA along the previous giuidewire and removed the BMW guidewire. During maximum hyperemia, the pressure wire was slowly pulled back from the distal coronary artery to the proximal portion of the coronary artery, thereby recording the pressure drop (△ pressure) across each of the individual stenosis during intravenous adenosine infusion. FFR values in the proximal and distal RCA stenosis were 0.87 and 0.52 after adenosine infusion, respectively. The △ pressure of distal stenosis was greater than the proximal △ pressure.(Figure 5) So, we decided to treat first the distal stenosis and then re-assess with FFR for the proximal stenosis. IVUS exam showed two tight stenoses of proximal to mid and mid to distal segment with relatively normal segment between two stenoses.(Figure 6) After predilatation with a 2.5 x 20 mm ELECT balloon, a 2.75 x 28 mm Xience V stent was deployed in the distal RCA with proximal stent landing on the normal segment.(Figure 7) Then, we performed reexamination of FFR, FFR value in proximal RCA after correction of distal stenosis was 0.68 that was still significant.(Figure 8) Based on the above result, we performed angioplasty of proximal RCA. After predilatation with the same balloon, a 3.5 x 28 mm Xience V stent was deployed on normal segment of mRCA, not overlapped between two stents.(Figure 9) Final right angiogram was good.(Figure 10) And then, left coronary artery(LCA) was engaged with an 8Fr JL4 guiding catheter. The LAD was wired with a 0.014” Floppy wire and the first diagonal branch was wired with the same wire sequentially. On IVUS exam, it showed diffue significant plaque in LM to mid LAD with cross sectional area (CSA) of 2.7 mm. FFR value of mid LAD was 0.79. Based on the above results, we performed angioplasty of LAD bifurcation with crush technique. Proximal LAD and diagonal branch were predilated with 2.0 X 20mm Black Hawk balloons respectively. We deployed Xience V 2.75 X 23 mm stent at the diagonal ostium.(Figure 11) After removal of stent balloon, the diagonal stent was crushed by a pLAD balloon. Then, we deployed Xience V 3.0 X 18 mm at pLAD. (Figure 12) After rewiring of the diagonal artery, kissing balloon inflations were done with Dura star 3.0 X 15mm and Dura star 2.5 X 15mm at pLAD and Diagonal branch, respectively.(Figure 13) Final left angiogram showed that the procedure was successful.(Figure 14, Figure 15)

Jingjin Che2010-10-24
The final stent in pLAD might be cross-over LM, but it seems unnecessary on CAG finding. Furthermore the stent was small to LM, and big to mid-LAD.
Young-Hak Kim2010-10-25
The lesion of LAD was extended to the ostial LAD involving the left main by IVUS exam. We are not very concerned about stent crossover to the left main when ostial LCX is free of disease. The stent size was also decided by IVUS, balancing the size of proximal and distal reference.
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