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LAD Ostial Lesion Treated by Crushing Technique
- Operator: Seung-Whan Lee, MD
Case Presentation
A 65-year-old man presented with an effort-related chest pain for one year. His coronary risk factors were hyperlipidemia and diabetes mellitus. His echocardiography showed normal left ventricular systolic function (EF=70%) without regional wall motion abnormality. Thallium scan showed reversible large sized perfusion defect at LAD territory.
Baseline Coronary Angiography
1. The left coronary angiogram showed subtotal stenosis at LAD ostium with TIMI 1 flow ( Movie 1, Movie 2, Movie 3).
2. The right coronary angiogram showed mild lesions at proximal to mid RCA and tight stenosis at postero-lateral branch ( Movie 4). Collateral flows from RCA to septal branches were also observed ( Movie 5).
Procedure
Five and Eight Fr sheaths were inserted into left and right femoral arteries, respectively. An 8 Fr JL 4 guiding catheter with side hole was engaged into left coronary artery ostium through right femoral artery. A 0.014 inch Fielder FC wire with a Finecross ® 130cm microcatheter was introduced into the LAD ( Movie 6) and was exchanged into a 0.014 inch BMW wire. Another 0.014 inch BMW wire and a 0.014 inch Fielder FC wire were placed into the first diagonal branch (D1) and LCX, respectively (Figure 1). And then, we performed intravascular ultrasound (IVUS) evaluations at the LM to LAD, D1, and LCX, respectively. Because LCX ostium was relatively preserved at IVUS examination, we planned to treat the LM to LAD and Di lesions with crushing technique. After predilatation with a Sprinter legend 2.5 x 20 mm balloon (Figure 2), we deployed a Resolute Integrity stent 3.0 x 30mm at the LAD (Figure 3). After a Resolute Integrity stent 3.0 x 30mm was deployed at Di, we deployed a Resolute Integrity stent 4.0 x 30mm at the LM to proximal LAD (Figure 4). Additional balloon dilatations were performed at D1 using Sprinter legend 2.5 x 20 mm balloon and Fortis NC 3.0 X 18 mm, sequentially (Figure 5). After dilatation with a Fortis NC 3.5 X 18 mm at the LAD, final kissing balloon dilatation was performed with a Fortis NC 3.5 X 18 mm at the LAD and a Fortis NC 3.0 X 18 mm at the D1 (Figure 6). Final angiogram showed that the procedure was successful ( Movie 7, Movie 8).
Long Bui2013-03-17
As spider view, LCX ostium seem to be normal and it is not true LAD ostium lesion, in fact. Why don't you protrude stent LAD into LM.
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