Left Main Shaft, proximal to mid LAD and proximal RCAdisease Treated by Simple Cross-Over Stenting

- Operator : Young-Hak Kim

Left Main Shaft, proximal to mid LAD and proximal RCAdisease Treated by Simple Cross-Over Stenting

- Operator: Young-Hak Kim, MD

Case Presentation

A 74 year-old gentlemancame to out-patient department with recently aggravated effort chest pain. His coronary risk factors werehypertension and hyperlipidemia. The physical examination and history showed highly unstable angina. The ECG showed anterior lead ST segment elevation (Figure 1) and cardiac enzyme was mild increased(CK-MB: 2.2 ng/ml, Troponin I: 0.239ng/ml).The patient was admitted to CCU and transferred to Catheterizationroom immediately for percutaneous coronary intervention.

Baseline Coronary Angiogram

A left coronary angiogram showed significantly diffuse narrowing of LM to mid LAD, tubular 80% stenosis of distal LCX ( Movie 1, Movie 2, Movie 3). A right coronary angiogram showed tubular 70% stenosis of proximalRCA and tubular 30% stenosis at at distal RCA ( Movie 4)

Procedure

An 8 Fr sheath was inserted through right femoral artery and an 5 Fr sheath was inserted through left femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 4 catheter with side hole. First, 0.014-inch BMW wire was inserted in LAD. Predilatations were performed with 2.5 x 20mm Tazuna balloon at LM and proximal LAD(Figure 2, Figure 3). We performed IVUS examination and IVUS showed significant stenosis from ostium of LM to middle LAD. Xience Xpedition stent 4.0 x 28 mm and 3.0 x 38 mm were implanted at LM to middle LAD (Figure 4, Figure 5). Thereafter, post-stenting adjunctive balloon dilatation using 4.0 x 28 mm and Empira NC 3.5(20) was performed at LM to middle LAD (Figure 6). After removing JL 4 catheter, the right coronary ostium was engaged with a 7 Fr JR 4 catheter with side hole. First, 0.014-inch BMW wire was inserted in RCA. An IVUS examination was performed and it showed tubular 70% stenosis of proximal RCA. The Xience Xpedition stent 4.0 x 18 mm was implanted at proximal RCA directly (Figure 7). The Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).