|LAD CTO Lesion with Previous Bifurcation Stenting|
|- Operator: Seung-Whan Lee, MD|
|A 61 year-old woman was referred for CTO intervention. She had a percutaneous coronary intervention of mLAD bifurcation lesion 4 years ago. She had suffered for effort angina about 4 month. The coronary angiogram showed totally occluded lesion at proximal LAD and mild stenosis at pLCX and pRCA. Her coronary risk factors were hypertension, diabetes mellitus, and dyslipidemia. The physical examination was normal. The ECG revealed old septal infarction and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=62%).|
|Baseline Coronary Angiography|
Both femoral arteries were inserted through 7F sheath. The left coronary artery was engaged with a 7 Fr XB 3.5 guiding catheter and right coronary artery was engaged with a 6 Fr JR 4.0 diagnostic catheter. Anterograde approach was tried. A 0.014 inch 180 cm Sion, 0.014 inch 190 cm fielder XT were used to cross LAD CTO lesion and finally 0.014 inch 180 cm Conquest pro wire supported by Corsair micro-catheter was crossed the LAD lesion. A 0.014 inch 180 cm Sion wire was placed at diagonal branch (Figure 1, Figure 2, Figure 3, Figure 4).
Predilatations were performed with Laxa Lacrosse 1.0 x 5 mm and Tazuna 2.5 x 15 mm balloon at mid LAD and diagonal branch severe times (Figure 5, Figure 6). As slow flow of LAD was observed after predilation, we decided to implant another stents at mid LAD ( Movie 4). After IVUS evaluation, Xience Alpine 3.0 x 38 mm and 4.0 x 33 mm stents were successfully deployed at LAD ostium to distal LAD (Figure 7, Figure 8). After stent implantation, diagonal branch was rewired with 0.014 180 cm Fielder XT wire. Digonal branch were dilated with Tazuna 1.25 x 10 mm and 2.5 x 20 mm balloons, and then drug coated balloon, SeQuent Please 2.75 x 17 mm were used at diagonal branch to prevent restenosis ( Movie 5, Figure 9, Figure 10). Post dilataion of proximal to distal LAD was performed with Pantera LEO 3.5 x 15 mm (Figure 11). At last, final kissing balloon was performed with Pantera LEO 3.5 x 15 mm balloon at mid LAD and Sequent Please 2.75 x 17 mm balloon at diagonal branch (Figure 12). Final angiography showed well expanded LAD and diagonal branch ( Movie 6).