Treatment of In-Stent Restenosis Lesion Involving Distal LMCA Bifurcation

- Operator : Seung-Jung Park

Treatment of In-Stent Restenosis Lesion Involving Distal LMCA Bifurcation
- Operator: Seung-Jung Park, MD
Case Presentation
A 60 year-old man was admitted with an effort-related chest discomfort for 4 months. About 5 years ago, he had PCI with Cypher stents 3.5 X 18 mm and 3.0 X 23 mm at the distal LM to mid LAD. His coronary risk factors were hypertension, hyperlipidemia, and diabetes mellitus. The treadmill test was positive at stage 2 with typical chest pain. Echocardiography showed preserved left ventricular systolic function (EF; 60%) without regional wall motion abnormality.
Baseline Coronary Angiography
1. The left coronary angiogram showed tight stenosis at ISR lesion involving distal LM bifurcation ( Movie 1, Movie 2). 2. The right coronary angiogram was near normal ( Movie 3). Collateral flows from RCA to left coronary artery were observed ( Movie 4).
Procedure
At first, we inserted the IABP catheter via left femoral arterial access. A 7 Fr JL 4 guiding catheter with side holes was engaged at the left coronary artery ostium through right femoral artery. A 0.014 inch BMW wire was introduced into the LAD. We tried to insert a wire into the LCX using a Crusade catheter, but the wiring was failed. Thereafter, we performed several balloon dilatations using a Ryujin 2.5 X 15 mm balloon at distal LM (Figure 1, Movie 5). And then, a 0.014 inch Choice PT wire could be introduced into the LCX (Figure 2). After predilation using a Ryujin 2.5 X 15 mm balloon at the proximal LCX (Figure 3, Movie 6), we deployed a Resolute Integrity stent 3.0 x 18 mm at the proximal LCX (Figure 4). Crushing was done with an Empira NC 3.5 X 15 mm balloon at LM to proximal LAD (Figure 5, Movie 7). After adjunctive balloon dilatation with a Maverick 1.5 X 15 mm balloon at proximal LCX (Figure 6), we performed kissing balloon dilatations with an Empira NC 3.5 X 15 mm balloon at the LM to proximal LAD and a Ryujin 2.5 X 15 mm balloon at the LCX (Figure 7). Next, we deployed a Resolute Integrity stent 4.0 x 18 mm at the LM to proximal LAD (Figure 8). After adjunctive balloon dilatation with Maverick 1.5 X 15 mm balloon and Ryujin 2.5 X 15 mm balloon at proximal LCX (Figure 9), final kissing balloon dilatation was performed with an Empira NC 3.5 X 15 mm at the LM to proximal LAD and an Empira NC 2.75 X 15 mm at the proximal LCX (Figure 10). Final angiogram showed well-expanded and well-positioned stents ( Movie 8, Movie 9).

Comments

  • Bing Liu 2013-03-16 Did the patient refused CABG£¿
  • Jong-Young Lee 2013-03-23 Honestly speaking, we strongly recommended bypass surgery after expalanation of risk of recurrent ISR, stent thrombosis and periprocedural risk. But after deep thought, patient and patient's family decided to undergo PCI.
  • Ricardo Arturo Quizhpe 2013-03-25 I would really treat the patient with PCI, because of the last chance before undergo CABG.
  • Richard Chan 2013-04-01 Excellent case Dr Park. I have a question - was LCx stent crushed and wire recrossed? Or was LAD wire pulled back and rewired across proximal LCx struts (Reverse Culotte) before Empira NC 3.5 dilation?
  • Wenduo Zhang 2014-06-11 I think this patient should take CABG first.

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