Distal left Main & Proximal LAD Disease Treated by Simple Cross-Over Stenting with FFR (Fractional Flow Reserve) Guidance

- Operator : Seung-Jung Park

Distal left Main & Proximal LAD Disease Treated by Simple Cross-Over Stenting with FFR (Fractional Flow Reserve) Guidance
- Operator: Seung-Jung Park, MD
Case Presentation
A 41 year-old man was admitted with effort chest pain for 2 months. His coronary risk factor was hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=70%) without regional wall motion abnormality. The thallium spect showed large reversible defect at anterior, anteroseptal, and anterolateral wall, as suggesting left main coronary artery stenosis. Baseline coronary angiogram showed tight stenosis at distal left main. Firstly we recommended bypass surgery, but he strongly refused it. So we decided to perform PCI at Left main stenosis.
Baseline Coronary Angiogram
1. A left coronary angiogram showed significant tight narrowing of distal LM ( Movie 1)
2. A right coronary angiogram was normal
Procedure
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 4.0 catheter with side hole. Firstly, two BMW 0.014-inch guidewire were inserted at LAD and LCX. We performed IVUS examination to determine the treatment strategy for the distal LM bifurcation disease. IVUS showed minimal stenosis at LCX ostium. Therefore, we intended to treat the lesion with simple cross-over technique. Predilatation was performed with a 2.5 x 20mm Sequent balloon at LM to pLAD (Figure 1). After predilatation, Promus Element stent 3.5 x 28mm was implanted at LM to pLAD (Figure 2). Thereafter, adjunctive post-stenting balloon dilatation using a 4.0 x 15mm Quantum balloon was performed at LM to pLAD. The following angiogram showed well-expanded stent, but intermediate stenosis at LCX ostium ( Movie 2). We checked LCX FFR, which was 0.88. Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 3, Movie 4).

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