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Proximal LAD Bifurcation Lesion Treated by Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 63 year-old man was admitted with effort chest pain for one year. His coronary risk factors were hypertension and diabetes mellitus . The echocardiography showed normal left ventricular function (EF=59%) without regional wall motion abnormality. Thallium scan showed partially reversible large sized perfusion defect at LAD territory.
Baseline Coronary Angiography
1. The left coronary angiogram showed tubular 90% stenosis of proximal LAD ( Movie 1, Movie 2, Movie 3, Movie 4, Movie 5).
2. The right coronary angiogram showed mild stenosis of mid RCA ( Movie 6).
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8Fr JL 4.0 catheter with side hole. Two 0.014 inch BMW wires were inserted into the LAD and the first diagonal branch. First, we checked the bifurcation lesion with IVUS( Movie 7: LAD, Movie 8: diagonal branch). We pre-dilated the LAD and the diagonal branch using a Ikazuchi 2.0 x 20 mm. Thereafter, we deployed a Xience Prime stent 2.75 x 23mm at D1 (Figure 1). We performed crushing with a Xience Prime stent 3.5 x 28mm at proximal LAD (Figure 2). Adjunctive post-stenting balloon dilatation was done using a Ikazuchi 2.0 x 20mm at the D1 and a Dura Star 3.5 x 20mm at the LAD. Additional kissing ballooning was performed by using a Dura Star 3.5 x 20mm at the LAD and a Dura Star 2.75 x 20mm at D1 (Figure 3). Final left angiogram and IVUS showed that the procedure was successful ( Movie 9, Movie 10).
Dobrin Vassilev2012-02-24
Good case! Why did you left mid-diagonal untreated?
Same question as the previous reader. You stent the diagonal branch with a 2,75 diamter stent, therefore it was a pretty large sidebranch, isn't it?
Zhonghan Ni2012-02-29
same question,the mid-Dia lesion looks so easy to stent,why not?
Xuebo Liu2012-03-05
If we do it , radial access and 6 F guiding Catheter is preferred using modified DK Crushing techniqe.
Long Bui2012-03-07
How about longterm outcomes (restenosis, thrombus) at overlaping site?
there are two lesions left untreated , the mid LAD and the mid diagonal. At least the mid LAD should have been tackled to ensure dital perfusion of LAD bed. The mid diagonal admittedly may make the procedure complicated but it is equally flow limiting.
Kunal Bikram Shaha2016-08-02
I think mid and distal LAD should have been assesed fo FFR after the two stent approach before ending the procedure.OR we sould have followed the rule of BIG DELTA BEFRE STARING THE procedure to see the functional significance of distal lesion,What is your opinion sir.
Se Hun Kang2016-08-02
Thank you for your comment. Although it was not presented, distal LAD was evaluated with IVUS and there was moderate stenosis and lumen was preserved. So we didn`t check FFR for the distal LAD. As you mentioned if we checked the FFR for distal LAD stenosis, we could have more objective findings about moderate distal LAD stenosis.
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