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LM with mLAD CTO Lesion Treated by Antegrade Approach

- Operator : Seung-Jung Park

LM with mLAD CTO Lesion Treated by Antegrade Approach
- Operator: Seung-Jung Park, MD
Clinical presentation
This patient was a 55-year-old man having a history of cerebral infarction 1 month ago. he already underwent angiography due to abnormal echocardiogram finding and diagnosed as LM with LAD CTO at outside hospital. Although bypass surgery was recommend as a primary treatment option, he was reluctant to surgery, therefore visited our hospital for secondary opinion. His coronary risk factor was hypertension. The ECG showed T-wave inversion in I, aVL, V5-6 leads and cardiac enzymes was unremarkable. The echocardiography showed severe LV dysfunction (EF=34%) with regional wall motion abnormality in LAD and LCX territories. thallium SPECT showed reversible perfusion defect in multiple areas.
Baseline coronary angiogram
1. The left coronary angiogram showed 60% narrowing of LM, diffuse 60% narrowing of pLAD and total occlusion from mLAD with TIMI 0 flow.( Movie 1, Movie 2)
2. The right coronary angiogram showed no significant luminal narrowing, grade 2 collateral flow was shown from RCA to LAD.( Movie 3)
Procedure
First above all, an IABP was inserted through Lt femoral artery. The left coronary ostium was engaged with an 8Fr JL4 SH guiding catheter through Rt femoral artery. A 5Fr JR4 diagnostic catheter was engaged in the right coronary artery through Rt radial approach. At first, by using a Finecross® 0.014 inch 1.8 Fr -130cm Coronary Micro-Guide catheter, wiring using Fielder XT 0.014 inch -180cm wire was antegradely tried into mLAD CTO lesion and passed the lesion.(Figure 1) We changed Fielder XT to BMW 0.014 inch -300cm wire. After removal of microcatheter, several balloon dilations with Maverick 2.0 X 20 mm was performed at proxymal to mid LAD.(Figure 2) After IVUS examination, another BMW 0.014 inch -190cm wire was positioned into the diagonal branch.(Figure 3) And further dilation was done at proximal to mid LAD with Amadeus 2.5 X 15mm balloon. Finally, balloon dilations with Nimbus Salvo 4.0 X 13mm was performed at LM.(Figure 4) The consecutive three Promus Element stent (4.0 X 20mm+3.0 X 28mm+2.5 X 28mm) were deployed at mid LAD to LM.(Figure 5) Post-adjuvant balloon dilation was done and the final angiogram showed successful results.( Movie 4)

Comments

  • Louie Fischer 2011-05-07 well done.good results but why did you exchange FXT for BMW was there any dissection? angiographically left main is not looking 60% can you post thepre PCI IVUS pictures?
  • Hagau Alexandru 2011-05-08 Very nice,the LAD is intramiocardic? What about the restenoze? Hagau Alexandru
  • Jong-Young Lee 2011-05-08 Thank you for your great comment and interest. We changed the initial Fielder XT wire to the conventional intermediate wire and then proceeded the intervention. This procedure was performed about 4 months ago. Until now there is no evidence of restenosis. The patient have been happy until now. On pre-PCI IVUS examination, there was a continuous, heavy plauqe from the proximal LAD to LM portion. So, we decided to cover the LM.
  • Anlin Lv 2011-05-08 It is very good. But his CTO case looks like simple. would you like to give us a difficult one?
  • Packirisamy Gobu 2011-05-08 the LAD distal to the stent is very thin. Is it diffusely diseased?

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