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Left Main Shaft, proximal LAD and distal LAD disease Treated by Simple Cross-Over Stenting
- Operator: Seung-Jung Park, MD
Case Presentation
A 60 year-old gentleman was admitted with effort chest pain for several months. His coronary risk factors were hypertension and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=57%) without regional wall motion abnormality. Treadmill test was positive and thallium test showed large reversible perfusion defect of LAD and RCA territory.
Baseline Coronary Angiogram
  1. A left coronary angiogram showed significant tight narrowing of distal LM to proximal LAD, tubular 80% stenosis of middle LAD, diffuse 60% stenosis of proximal LCX. Additionally, intermediate stenosis were observed at D1, OM ( Movie 1, Movie 2, Movie 3).
  2. A right coronary angiogram showed diffuse 70% stenosis of proximal to middle RCA and total occlusion at distal RCA ( Movie 4)
Procedure
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr XB 3.5 catheter with side hole. First, by using the FINECROSS 0.014-inch 1.8Fr microcatheter, 0.014-inch Shinobi guidewire was inserted in LAD. After that wire was exchanged by 0014-inch BMW 300cm guidewire. Predilatations were performed with 2.5 x 20mm TREK balloon at proximal LAD and middle LAD (Figure 1, Figure 2). We performed IVUS examination and IVUS showed significant stenosis from distal LM to middle LAD. Resolute intergrity stent 2.5 x 18mm, Resolute intergrity stent 3.5 x 22mm and Resolute intergrity stent 4.0 x 34mm were implanted at middle LAD to LM (Figure 3, Figure 4, Figure 5). The Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).
Long Bui2014-07-23
I agree with you about cross-over intervetion. Why don't you insert another wire in LCX, althought LCX ostium is seem to be normal? I routinely use 2 wire for this situation.
ahn jung min2014-07-23
Thank you for your comment. After IVUS evaluation, we realized that LCX ostium was widely-open, so we did not insert LCX wire. However, as Dr. Antonio Colombo always said, there was nobody to blame for inserting LCX wire even though in a case like this.
Long Bui2014-07-23
Thank you for your comment. Tomorow I will do a case like this. But I don't have IVUS. It's difficult to define LCX ostium situation. So it's safe to use 2 wire technique. After predilate LM-LAD lesion, the disection of LAD ostium could reach to LCX osmium. This is the reasion that I must use another wire in LCX.
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