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Diffuse tandem stenoses in LAD treated by step-by-step approach using FFR guidance
- Operator: Seung-Jung Park, MD
Clinical history

A 51 year-old female presented with effort-related chest pain for 2 month. She suffered from exertional dyspnea for 3 years. She had a past medical history of hyperlipidemia and hypertention. Her resting ECG and echocardiogram were normal.

Baseline coronary angiogram

A left coronary angiogram showed severe stenosis in distal LCX. The LAD had two significant stenoses in proximal and mid segment, respectively. The latter one had a nearly right angle (Figure 1, Movie 1).

Procedure

Left coronary artery was engaged with a 7Fr XB 3.5 guiding catheter with side holes. We placed a pressure wire in the distal LAD segment beyond the mid LAD stenosis. After adenosine infusion at 140mcg/kg/min to obtain maximum hyperemia, the FFR value in the distal LAD was 0.62 and then the pressure wire was slowly pulled back during adenosine infusion. The FFR value in-between those two diseased segments was 0.78 and the value in the proximal LAD prior to the 1st stenosis rose up to 0.99 (Figure 2). The pressure difference (△ pressure) by FFR across the proximal stenosis was greater (0.21) than that of the distal stenosis (0.16). Thus, we treated the proximal lesion firstly with pre-ballooning (Elect 2.5 x 20 mm) and stenting (Xience V 3.5 x 28 mm) (Figure 3, Figure 4). After optimizing the stent using a non-compliant balloon (Dura Star 3.5 x 15 mm), the FFR value in distal LAD was rechecked. It was 0.56 with maximum hyperemia which had a hemodynamic significance ( Movie 2, Figure 5). The distal lesion was pre-dilated with the Elect 2.5 x 20 mm balloon and a Xience V 3.0 x 23 mm stent was placed with overlap (Figure 6, Figure 7). Adjunctive balloon dilatation was done with stent balloon (Figure 8). The final angiogram showed a good result with TIMI 3 flow ( Movie 3).

Guanghui Chen2011-01-30
the result is almost perfect. the interventional strategy was scientically made in terms of not only the angiographic but the FFR result, it is incredibly convincing. well done!
Jong-Young Lee2011-01-30
Thank you for your interest and your sincere agreement. Recently, we used FFR assessment in the complex coronary lesion subsets such as LM, bifurcation and tandem lesions. Especially in the tandem lesions, the FFR could be good indicator of treat or not treat. This case is one of typical "FFR guided spot stenting" cases, which we have recently gathered. Pijls NH and De Bruyne have already set up the basic concept of FFR in tandem lesions (Circulation 2000;101 and 102). In practical point of view, we made a simple mathematical formula (rule of big Delta) to define which lesion would be functionally more significant between the two serial stenosis. We defined "functional lesion length" by FFR and then, just calculated the delta pressure from the absolute FFR value of proximal(Pa), mid(Pm) and distal portion(Pd) (Figure 2). For particular this case, proximal delta pressure (Pa-Pm=0.21) was significantly bigger than that (Pm-Pd=0.16) of distal one, which meant proximal lesion would be functionally more significant. The reason why we treated proximal lesion first and reassessed the FFR for the remained distal lesion. So we did treat according of FFR 0.56 which have a hemodynamic significance. Using FFR, we could avoid the unnecessary procedure for hemodynamically not-significant lesion even in the tandem lesions.
yu tao2012-10-04
Perfect case! After deploying the first stent, do you think how to choose the optimal cut off FFR value for the second stent? Thank you!
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