Treatment of Proximal Edge ISR with LM Ostial Involvement and Proximal LCX ISR in Patient Who Underwent 'Crushing Technique' at Distal LMCA Bifurcation

- Operator : Seung-Jung Park

Treatment of Proximal Edge ISR with LM Ostial Involvement and Proximal LCX ISR in Patient Who Underwent 'Crushing Technique' at Distal LMCA Bifurcation

- Operator: Seung-Jung Park, MD

Case Presentation

A 43 year old man was admitted with effort chest pain for 3months. He received a PCI at distal LM bifurcation with 3.5 x 28mm Promus element stent for distal LM to proximal LAD and 3.0 x 24mm Promus element stent for proximal LCX using ‘Crushing technique’ 8 months ago. He is a current smoker. The echocardiography showed normal left ventricular function (EF=67%) without regional wall motion abnormalities. Treadmill test was positive at stage 2 and thalium SPECT showed paritial reversible large defect in LCX territory.

Baseline Coronary Angiography

The left coronary angiogram showed tight stenosis at proximal edge with LM ostial involvement and diffuse severe ISR of proximal LCX. Distal LM to pLAD stent was relatively patent ( Movie 1, Movie 2). The right coronary angiogram showed minimal disease.

Procedure

An 8F sheath was inserted through right femoral artery and the left coronary ostium was engaged with an 8F XB 3.5 guiding catheter. Two 0.014 inch BMW wires were inserted into the LAD and LCX. Because the lesion could not be covered with one stent, we decided to use a stent for proximal ISR lesion of LMCA and a drug eluting balloon for LCX ISR lesion. After predilation, 3.5 x 13mm Cypher stent was implanted at LM ostium to proximal edge of previous stent with postdilation with 3.5 x 20mm NC balloon (Figure 1). The LCX ISR was predilated with 3.0 x 20mm NC balloon several times and instent kissing balloon angioplasty was performed at LM bifurcation (Figure 2, Figure 3). Finally, we used a drug eluting balloon for LCX ISR lesion (Figure 4). Final angiogram showed a good result with well-expanded stent ( Movie 3, Movie 4).