Slides Coronary Left Main

LM Bifurcation- LAD Crossover

- Operator : Nicolaus J. Reifart

LM Bifurcation- LAD Crossover
- Operators: Nicolaus J. Reifart, MD, Soon Jun Hong, MD
Clinical Information

- Relevant clinical history and physical exam:
A 68-year old woman was admitted with effort chest pain for 1 week. The coronary MDCT showed triple vessel disease with left main coronary artery disease. Therefore, she underwent stenting with 3.5 x 28 mm and 3.5 x 23 mm Cypher stent in proximal to mid RCA 1month ago. And she was planned to undergoing PCI at left main coronalry artery lesion. She has a diabetes, hypertension and dyslipidemia.

- Relevant test results prior to catheterization:
The ECG showed no significant ST changes. The echocardiography showed normal LV systolic function without wall motion abnormality.

- Relevant catheterization findings:
Baseline coronary angiogram showed a diffuse 70 % narrowing of LM, intermediate lesion of proximal LAD and proximal LCX (Figure 1, Figure 2). The stent of RCA was patent.

Interventional Management
- Procedural step:
8 Fr Judkins 4.0 guiding catheter was engaged in the left coronary artery through the femoral approach. 0.014 inch guide wire (BMW) was passed through the LAD and LCX. Predilation of dLM to LAD with 3.5 x 20mm noncompliant balloon (Quantum) was done (Figure 3). And then, 3.5 x 23mm XIENCE stent was deployed at pLAD to LM across LCX with protection (Figure 4). After stenting, additional high pressure balloon dilation with 4.0 x 20 Quantum ballonon was done. The final angiogram showed excellent result. (Figure 5, Figure 6)

Comments

  • Premchand Rajendra Kumar Jain 2009-05-09 is there no need to do lcx bifurcation in this type of approach
  • Soon Jun Hong 2009-05-18 We performed IVUS starting from mid LAD and mid LCX, and there was no significant plaque burden at LCX ostium. After left main stenting extending from proximal LAD, there was no flow limitation to LCX. In this case, we were confident after index IVUS examination that there was no need for further intervention for LCX ostium.
  • Nicolaus J. Reifart 2009-06-01 I agree with Dr. SoonJun Hong - in this case our IVUS impression was benign. If a bifucation like LM-LAD - CX opens at 90 degrees and the sidebranch (CX) is not considerably diseased/stenosed, it is very rare that you need to touch it. If the stenosis appears > 70% angiographically, you should use FFR to evaluate its relevance. IVUs can be used as well, but mostly results in unnecessary dilation and stenting.

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