Slides
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). |
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