Decision Making Using with Fractional Flow Reserve after LAD Bifurcation ISR Lesion Treated with Simple Cross-Over Technique

- Operator : Seung-Jung Park

Decision Making Using with Fractional Flow Reserve after LAD Bifurcation ISR Lesion Treated with Simple Cross-Over Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 66 year-old man was admitted with effort chest pain for 3 days. 10-years ago he had underwent PCI on LAD bifurcation lesion (BMS) with kissing ballooning of diagonal branch. His coronary risk factors were hypertension, diabetes mellitus, and ex-smoker. The physical examination was normal. The ECG were unremarkable. The cardiac marker was elevated and the echocardiography showed RWMA in LAD territory with preserved EF (64%).
Baseline Coronary Angiography
The left coronary angiogram showed subtotally occluded LAD bifurcation with TIMI grade 2 flow ( Movie 1, Movie 2). The right coronary angiogram showed minimal disease.
Procedure
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 3.5 catheter with side hole. Three 0.014 inch BMW wires were inserted into the LAD, and diagonal branch. We examed lesions with IVUS to make a decision. IVUS examination revealed relatively normal diagonal ostium (Figure 1). So, we intended to treat the lesions with simple cross-over technique. Predilatation was performed with a 2.5 x 20mm Maverick balloon at pLAD (Figure 2). After predilatation, Resolute Integrity stent (3.5x26mm) were implanted at dLM to pLAD (Figure 3). And then, postdilatation using a 3.5 x 15mm Empira NC balloon and 4.0 x 8mm Quantum balloon was performed. The following angiogram showed well-expanded stents, but stenosis of diagonal ostium was observed ( Movie 3). We checked diagonal FFR, which was 0.89. Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).

Comments

  • Kunal Bikram Shaha 2016-07-29 Sir a current study from Mount sanai by Dr Annaporna says that SB occlusion is dependent upon the amount of lipid arc adjacent to the ostium that used OCT as a tool.What is your opinion?
  • Kunal Bikram Shaha 2016-07-29 Sir can we use DEB in such case
  • Se Hun Kang 2016-07-29 Thank you for your comment. As you mentioned the amount of lipid is a one of the predictors of side branch occlusion. But previous studies reported that lesion characteristics such as lesion length of side branch, stenosis of main branch and technique including preballooning were also predictors of side branch occlusion You might mean the use of DEB for diagonal branch. But in this case FFR value of diagonal branch after stent implantation was 0.89, it means the stenosis was not significant. So we choose the medical treatment for diagonal branch.

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