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Heavy calcified LM to LAD stenosis treated by rotabulation and simple cross over stenting

- Operator : Seung-Jung Park

Heavy calcified LM to LAD stenosis treated by rotabulation and simple cross over stenting
- Operator: Seung-Jung Park, MD
Relevant clinical history and physical exam
A 58 year-old woman visited our hospital because of recurrent episodes of dyspnea. She already underwent angiography and diagnosed as coronary arterial disease involved left main and triple vessels at outside hospital. Although bypass surgery was recommend as a primary treatment option, she was reluctant to surgery, therefore visited our hospital for secondary opinion. Her coronary risk factors were hypertension and smoking.
Relevant catheterization findings
Left coronary angiogram showed severe stenosis with heavy calcification diffusely involving from LM to mLAD artery.( Movie 1) Also right coronary angiogram showed diffuse stenosis with calcification involving whole segments.
Procedural step
First above all, to support the patient’ hemodynamics during procedure, prophylactic IABP insertion was done. Then, Lt JL4 8Fr guiding catheter was engaged into the LMCA. Conventional 0.014 inch wires were inserted into LAD and LCX, respectively. For the delivery of balloon and stent, we needed several times of rotablation with 1.25(210000 burr) and 1.5mm(210000 burr) due to heavy calcification.( Movie 2) Thereafter, we could do the balloon dilatation using 2.5X2.75mm balloon upto 20 atm at proximal to mid LAD.( Movie 3) After rotablation and balloon inflation, we checked IVUS cautiously and placed the 3 consecutive Promus Element stents (3.5, 3.0 and 2.75mm) with simple cross-over technique from mLAD to LM.( Movie 4) Thereafter, post adjunctive balloon dilatation was done.( Movie 5) After kissing-balloon at proximal LCX and LAD at distal LM bifurcation,( Movie 6) we finished procedure. ( Movie 7, Movie 8)

Comments

  • Ayhan Olcay 2011-03-26 Dr Park very good case. Do you think Promus Element with higher radial strength is more desirable in osteal lesions (RCA ostium, LM PCI) ? I used it for RCA osteal restenotic lesion recently, assuming better radial scaffolding is good in this location. Do you have an idea about protruding inadvertantly osteal LM or RCA stent 4-5 mm out of ostium ? Any experience with such patients ? Could higher radial strength stents induce more tissue reaction in the vessel in long term and lower DES effectiveness ? Thank you
  • Anshul K Jain 2011-03-26 Dr Park- a great case. What anti platelet drug regime do you use in such cases- especially with rotational atherectomy of a long segment?
  • Seung-Jung Park 2011-03-27 Although we have no data, I believe that higher radial force with tube like designed stents may be beneficial for ostial lesion PCI. Proximal protruding of stent at out side of ostium would be OK whatever the length is. However, the shorter would be the better for the repeat procedure. In my experience, the self-expanding stent larger than reference vessel diameter may have more tissue reaction after the stent over time, however, appropriate stent size selection (at least 1:1 media to media by IVUS) with higher pressure inflation and higher radial force would be OK. Regarding the antiplatelet therapy for those complex PCI patients, we prefer triple antiplatelet therapy (Aspirin, Plavix and Cilostazol) for at least 6 months and aspirin+plavix for 1 year. Thank you for your interests.

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