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Left Main to Proximal LAD and LCX Disease Treated by Simple Cross-Over Stenting
- Operator: Seung-Jung Park, MD
Case Presentation
A 72 year-old man was admitted with effort chest pain for 2 months. His coronary risk factors were hypertension, diabetes, hyperlipidemia and ex-smoking. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=66%) without regional wall motion abnormality. Cardiac stress perfusion CT showed significant stenosis with reversible perfusion defect of LAD territory.
Baseline Coronary Angiogram
  1. A left coronary angiogram showed significant stenosis of LM to proximal LAD, intermediate stenosis of LCX ostium. Additionally, intermediate stenosis were observed at middle LAD, diagonal ( Movie 1, Movie 2, Movie 3).
  2. 2. A right coronary angiogram showed normal coronary artery ( Movie 4).
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 holes. Then 0.014-inch 190 cm BMW wire and 0.014-inch 180 cm Sion wire were inserted in LAD and LCX sequentially (Figure 1). We performed IVUS evaluation of LCX and middle LAD to LM lesion. The IVUS imaging revealed that LCX ostium was preserved (Figure 2). Therefore, we decided to perform one stent strategy with simple cross-over stenting. Direct stenting with Xience Xpedition stent 4.0 x 23mm was done at LM to proximal LAD with instent balloon dilatation up to 14 atm (Figure 3). Post stent IVUS evaluation was performed. IVUS imaging showed well positioned and expanded stent. And CAG showed that LCX ostium remained patent. So, we didn’t perform additional kissing balloon. The Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).
CAG showed a patent LCx but still with at least 70 to 80% ostial stenosis. An FFR would be a better option if LCx lesion should be intervene or not
Kunal Bikram Shaha2016-08-04
would you like to commenrt over the oversizing of stent.what is your opinion ?Though sir Park knows left main than any of us and he likes to bit ovrsize.May I know the reason why?Or its a message that Not less than 3.75 to 4 stent to be deployed in left main proximal lad segment
Kunal Bikram Shaha2016-08-04
sir have we done any study about virtual histology of the left main that supports left main being more muscular and elastic can accomodate bigger stent than it appears to be.
Se Hun Kang2016-08-04
Thank you for your comment. First, as you see in IVUS image of LAD with LCX ostium, vessel diameter was more than 4.0 mm. So the choice of 4.0 x 23 mm stent for LM to proximal LAD was not considered as oversize of stent. You`ve already known about the 5,6,7,8 rules and this case matched the rule well. Additionally, SJ park said 'Even in the era of DES, I still prefer The bigger, the Better." Second, although there is limited data about the elasticity of left main separately. It it known as the resting coronary blood flow under normal hemodynamic conditions averages 0.7 to 1.0 mL/min/g and can increase between four- and fivefold during vasodilation.
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