Left Main Shaft & proximal LAD disease Treated by Simple Cross-Over Stenting

- Operator : Seung-Jung Park

Left Main Shaft & proximal LAD disease Treated by Simple Cross-Over Stenting
- Operator: Seung-Jung Park, MD
A 75 year-old gentleman was admitted with effort chest pain for several years. His coronary risk factor was hypertension. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=70%) without regional wall motion abnormality. Treadmill test and thallium test were not done.
Baseline Coronary Angiogram
1. A left coronary angiogram showed significant tight narrowing of LM shaft and proximal LAD. Additionally, tight stenosis was observed at OM and intermediate stenosis was observed at mLAD ( Movie 1, Movie 2, Movie 3)
2. A right coronary angiogram was normal
Procedure
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 4.0 catheter with side hole. First above all, we intended to treat the OM stenosis. BMW 0.014-inch guidewire was inserted at OM and predilatation was performed with a 2.5 x 15mm Maverick balloon. Subsequently, Endeavor Integrity stent 3.0 x 18mm was implanted and post-stenting adjunctive balloon dilatation was done by using a 3.5 x 15mm Dura Star balloon (Figure 1, Movie 4). Thereafter, another BMW 0.014-inch guidewire was inserted at LAD. Predilatation was performed with a 2.5 x 15mm Maverick balloon at LM to pLAD (Figure 2). After predilatation, Promus Element stent 4.0 x 28mm was implanted at LM to pLAD (Figure 3). Thereafter, post-stenting adjunctive balloon dilatation using a 4.5 x 15mm Quantum balloon was performed at LM to pLAD. The following angiogram showed well-expanded stent. Finally, we checked mLAD FFR, which was 0.86. Therefore, we deferred PCI for the intermediate stenosis of mLAD. Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).

Comments

  • Klaus Lang 2011-08-05 What about the stent struts overlapping the RCX-ostium? Whatt¢¥s the reason for not dilating the Stentostium to the RCX? Klaus Lang, Saarbrücken, Germany
  • Jingjin Che 2011-08-06 Good result! This case is a typical example for cross-Over Stenting. Did the stent at LM to pLAD cover the ostium of LM?
  • Won-Jang Kim 2011-08-06 Thanks for colleagues' comments. Yes, we covered the ostium of LM. Before the LM stenting, we evaluated the LCx ostium by IVUS, which showed minimal plaques. We didn't touch the LCx ostium based on the post-IVUS evaluation. It was stent struts, crossed the LCx ostium, not a plaque shift.
  • Chunguang Feng 2011-08-07 Good result!But I wonder why didnt you choose 3.5mm stent at first in OM lesion? XuZhou,china
  • Won-Jang Kim 2011-08-07 For the OM lesion, it was difficult to pass through IVUS catheter, and we initially chose the stent size by angiographically. Thereafter, we evaluated IVUS for the post-stent optimization.
  • Lijun 2011-08-09 Saved OM, lost d-LCX? D-LCX must be evaluated by IVUS or FFR.
  • Won-Jang Kim 2011-08-09 We did an IVUS examination after stening and revealed well preserved LCx proper.
  • Marcelo Ribeiro 2011-08-14 One more example of the fantastic talent of Dr Park. This was a very challenging case as you could have a deterioration of the left main lesion during pci of LCX, so it emphasizes the high level of expertise of the operator, but also the high quality of anti thrombotic and anti platelet treatments nowadays. My questions are divided in two subjects: what is your pharmacological adjunct treatment for these complex cases and how do you manage the discussions of cases in your center, considering these controversial cases, i mean, are the decisions taken in the cath lab or are there multi disciplinary discussions?
  • Won-Jang Kim 2011-08-14 We treat the LM lesion with standard dual antiplatelet therapy (aspirin+plavix), except for the diffuse long lesions, restenosis, or multiple stents overlapped in LM. Those complex cases are treated with triple antiplatelet therapy (aspirin+clopidogrel+cilostazol) based on the operator's discretion. We usually discuss about the complex cases, including LM. If we decided the operation, we also discussed with cardiac surgeon for those cases.
  • Seung-Jung Park 2011-08-15 Thanks for nice comments on this case. This case would be typical example of "Functional Angioplasty" supported by IVUS and FFR. At first, the pre-PCI IVUS evaluation give us more understanding about inside of the vessel (extension of disease for LCX ostium, true reference vessel diameter, degree of remodeling, and plaque characteristics ets). Therefore, we can choose SIMPLE treatment strategy(single stent cross over) and large diameter stent too. Regarding the mLAD lesion, the meaning of FFR 0.86 was absolutely no evidence of clinical ischemia (specificity 100%). Regarding the compromised LCX proper after OM stenting, the jeopardy myocardium of OM should be bigger than LCX roper, and compromised LCX proper ostium would be functionally normal although it looked visually significant. I believe the long-term clinical outcome of summation of these angoiplasties would be good. Thank you all again for the advanced interests.

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