Tight ISR of Proximal LCX Lesion Treated with Drug Eluting Balloon and Distal Edge ISR of Proximal LAD Stent with Drug Eluting Stent

- Operator : Ron Waksman

Tight ISR of Proximal LCX Lesion Treated with Drug Eluting Balloon and Distal Edge ISR of Proximal LAD Stent with Drug Eluting Stent

- Operator: Ron Waksman, MD

Case Presentation

A 59-year old man was admitted for scheduled follow-up coronary angiography. About 9 months ago, he received multiple stent implantations with Xience V stents at LM to proximal LAD (Xience 3.5 x 28 mm), proximal LCX (Xience V 3.0 x 28 mm), diagonal branch (Xience V 2.5 x 28 mm) and middle to distal RCA (Xience V 3.5 x 28 mm, 3.0 x 28 mm). His coronary risk factors were diabetes mellitus and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=57%) with hypokinesia of basal inferior and mid posterior wall. Thallium test showed partially reversible perfusion defect in LCX territory and reversible perfusion defect in LAD territory.

Baseline Coronary Angiography

The left coronary angiogram showed tight ISR of LCX ostium, tight distal edge ISR of proximal LAD stent and 80% discrete narrowing of distal LAD. ( Movie 1) The right coronary angiogram showed patent previous stents and intermediate disease in proximal RCA. ( Movie 2)

Procedure

An 8F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with a 7F XB SH catheter with 3.5 cm curve. A 0.014 inch BMW wire was inserted into the LAD. Distal LAD was predilated with 2.5 x 12 mm Sprinter balloon. (Figure 1, Figure 2, Figure 3) A 0.014 inch floppy BMW wire was inserted into the LCX. A 0.014 inch Fielder FC wire was inserted into RI. (Figure 4) After that, proximal LCX was predilated with 2.5 x 12 mm Sprinter balloon and 3.0 x 20 mm SeQuent Please (drug eluting balloon). (Figure 5, Figure 6, Figure 7, Figure 8) And then a 0.014 inch BMW wire was reinserted into LAD. However, stent catheter did not pass into the LAD. So, we predilated middle LAD with 2.5 x 12 mm Sprinter balloon and insert a 0.014 inch Fielder FC wire into the LAD for back up. A 2.5 x 12 mm Promus element stent was implanted at distal LAD. And then 2.75 x 12 mm Promus element was implanted at middle LAD. (Figure 9, Figure 10) Final angiogram showed a well-expanded stents without residual narrowing. ( Movie 3)