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Repeat Kissing Stenting for Proximal Edge ISR after Kissing Stenting in Left Main Coronary Artery Stenosis

- Operator : Seung-Jung Park

Repeat Kissing Stenting for Proximal Edge ISR after Kissing Stenting in Left Main Coronary Artery Stenosis
- Operator: Seung-Jung Park, MD, Korea
Case presentation : Presented at Oct 21, 2003
A 63-year old male patient underwent ¡°kissing stenting¡± with two 3.0x18mm Cypher stents for left main (LM) bifurcation lesion 6 months ago (Figure 1, Figure 2, Figure 3, Figure 4). He was very happy with the result and no chest pain occurred during 6 months. He was admitted for a routine follow-up angiography.
Baseline angiography
Follow-up angiography was performed with a 5F Judkins catheter through the radial approach. Left coronary angiogram was shown in Figure 5, Figure 6. Unfortunately the proximal edge of the stents, ostial LM, appeared to be narrowed. The in-stent segments of both stents were perfectly patent.
Planned strategy
Although we recommended bypass surgery to the patient, he refused our medical advice. Therefore, we performed intravascular ultrasound (IVUS) first for complete evaluation of the edge restenosis lesion.
Procedure

A 7F sheath was inserted through right femoral artery and the left coronary was engaged with a 7F XB catheter. A 0.014 inch Floppy wire and a 0.014 inch Choice PT wire were inserted into the LAD and LCX, respectively. Because the wire could be crossed into the opposite stent through the overlapped stent strut in the LM, we tried to introduce a conventional balloon catheter and an IVUS catheter very carefully to verify proper positioning of the wires. After assuring the position of the two wires in the LAD and LCX, we obtained the IVUS images. IVUS image showed that the LM ostium was not covered with the two stents and had a tight stenosis with abundant plaque (Figure 7, from LAD to LM). The stented segments of the two stents were patent. By side-by-side comparison of the IVUS images at the index procedure and follow-up (Figure 8), we realized that the ostial LM with significant plaque was not covered with the stents at the index procedure and the stenosis was aggravated at follow-up. We intended to treat the lesion with repeat kissing stenting. After kissing balloon inflation (Figure 9), two 3.0x8mm Cypher stents were implanted with ¡°kissing stenting¡± technique simultaneously (Figure 10). The result was very good (Figure 11, Figure 12). IVUS evaluation after procedure showed that the LM ostium was completely covered with the two stents. And the two stents were overlapped with the previously implanted two stents (Figure 13, from LAD to LM).

Follow up angiography
At 6 months after the repeated kissing stenting, the follow up coronary angiography was performed with a 5F Judkins catheter through the radial approach. The left coronary angiogram showed patent stented segments (Figure 14, Figure 15).

Comments

  • Seong-Wook Park 2004-04-17
  • Seong-Wook Park 2004-04-17
  • Yong He 2004-04-25 Dear Dr Park,I wonder if the kissing stenting would increase the risk of subacute thrombolization because too much stent struts were amassed in the middle of lumen, do you have any data about the incidence of subacute thrombolization after kissing stenting? Dr Yong He from China
  • Seung-Jung Park 2004-05-15
  • Seung-Jung Park 2004-05-15
  • Seung-Jung Park 2004-05-20 First of all, I would like to apologize the dealyed response. We had some technical problems in soft ware programming. In terms of SAT, we have no experience yet among 130 patients with unprotected left main stenting. Actually, we used triple combination of antiplatelet regimen, aspirin, clopidogrel and cilostazole without 2b/3a inhibitors. Thanks !
  • Yong He 2004-05-22 Thank you for your reply.

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