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Proximal edge ISR of LAD Stent Involving LMCA Bifurcation Treated with Simple Cross-Over Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 63 year-old man was admitted with recurrent chest pains. One-year ago, he had got PCI on proximal to distal RCA (Xience 3.5 x 23mm, 3.5 x 28mm, 3.0 x 28mm), proximal LAD (Promus 3.0 x 20mm), and diagonal (Promus 2.5 x 28mm). His coronary risk factors were hypertension, diabetes and dyslipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=59%) with newly developed apical hypokineaia. Treadmill test is positive and thallium test showed reversible perfusion defect in multiple areas.
Baseline Coronary Angiography
The left coronary angiogram showed tight ISR of LAD ostium, 50% narrowing of LM, intermediate lesion of mid to distal LAD, and diffuse subtotal narrowing of distal LCX. ( Movie 1, Movie 2) The right coronary angiogram showed intermediate disease.
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8F JL catheter with 4.0 cm curve. A 0.014-inch Soft wire was inserted into the LCX. We failed several times for guidewire to pass into the LAD. Finally, by using the Crusade microcatheter, a 0.014-inch Fielder FC guidewire was inserted into LAD. After that, wire was exchanged by a 0.014-inch BMW guidewire. Proximal LAD to LM was predilated with 2.5 x 15mm Maverick balloon and 3.5 x 20mm Ryujin balloon. (Figure 1, Figure 2) And then 4.0 x 20mm Promus element stent was implanted at proximal LAD to LM (Figure 3) with post-dilatation using a 4.0 x 15mm Voyager NC balloon. (Figure 4) Final angiogram showed a well-expanded stents without residual narrowing. ( Movie 3, Movie 4)
Li Wah Tam2011-04-23
Dear Dr. Park , Excellent skill in wiring the LAD. Just want to ask. Are you using the crusade micro-catheter , loading on the Lcx wire for wiring the LAD , or just for exchange the “ dangerous” Fielder GW for a soft BMW GW ? Regards, Li wah Tam (HK)
Young-Hak Kim2011-04-23
I performed the procedure with Dr. Park. The crusade catheter was used with the two purposes to facilitate the wire delivery to LAD and exchange the wires if needed.
Faris Basalamah2011-04-25
Dear Dr.Park, why you were not considered to open the distal LCX? because thalium scan showed multiple ischemic area that could be from LCX area also. Second question in crossover stenting from LAD to LM, the non small LCX ostial was "closed" by stent struts, how long we should give dual anti platelet? because perhaps there wouldn't be endothelization of the stent struts in the ostial LCX area, isn't? Faris Basalamah (Indonesia)
Young-Hak Kim2011-04-25
The disase severity of distal LCX lesion had not changed for the period between the first and second procedures with collateral from the RCA. When one-stent crossover technique is used, final kissing balloon inflation is not routinely performed. Dr. Park suggests it when the LCX has deteriorated TIMI flow, significant jail (at least more than 50% stenosis or FFR < 0.8), or dissection.
Ayhan Olcay2011-04-26
Dr Park congradulation for the case. Do you think proximal stenosis to the stent is due to excessive device use and iatrogenic vessel trauma (IVUS pre-post procedure, excessive NC balloon postdilatation, deep catheter intubation, multiple wires, protrusion of postdilatation balloon to normal vessel segment). Thank you for sharing your cases.
Young-Hak Kim2011-04-28
The mechanism of proximal edge restenosis is not clear. However, across the studies, it seems to be consistent that proximal edge is relatively prone to restenosis because of insufficient drug effusion, any mechanicam trauma applied during the procedure or other unknown mechanmisms. In addition, we cannont exclude the possibility of stent-related difference in the region.
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