LM Bifurcation Lesion Treated by TAP Technique and Drug Eluting Balloon

- Operator : Duk-Woo Park

LM Bifurcation Lesion Treated by TAP Technique and Drug Eluting Balloon
- Operator: Duk-Woo Park, MD
Case Presentation
A 56 year-old male was referred to our hospital for a second opinion. 4 years ago, he underwent primary PCI for the ST elevation MI and DES was implanted in LAD in other center. After index procedure, he underwent 4 times of additional balloon angioplasty due to in stent restenosis and side-branch occlusion. About 4 months ago, effort chest pain was recurred. He underwent coronary angiogram which revealed severe ISR at proximal LAD with concomitant involvement of LCX os. His coronary risk factor was ex-smoker and hyperlipidemia. His baseline ECG and cardiac markers were unremarkable.
Baseline Coronary Angiography
  1. The left coronary angiogram showed significant ISR in the mid and distal portion of previous stent of pmLAD with tight stenosis of LCX os ( Movie 1, Movie 2).
  2. The right coronary angiogram showed diffuse intermediate disease with FFR value of 0.85 ( Movie 3).
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8F JL 4 catheter. The 0.014-inch 190cm BMW wire was inserted into the LAD and another BMW wire was inserted into the LCX. After IVUS, proximal to mid LAD was dilated with 4.0 X 15mm Tazuna balloon (Figure 1). The ISR lesion was successfully dilated with balloon angioplasty ( Movie 4). Two drug eluting balloons (Sequent please 3.5 X 20mm and 3.0 X 20mm) were applied subsequently to prevent restenosis (Figure 2). LCX was rewired with Choice PT 0.014 inch wire. After dilatation with 2.0 X 15mm Tazuna balloon, Promus premier (Synergy) 2.75 X 32 mm stent was implanted at proximal LCX (Figure 3). And then kissing ballooning was performed by using a 3.5 X 15 mm non-compliant (NC) Quantum balloon at LM to proximal LAD and 2.75 X 15mm NC Quantum balloon at LM to proximal LCX (Figure 4). Final left angiogram showed successful result ( Movie 5, Movie 6).

Comments

  • Jae Hong Park 2016-06-19 Thanks for the excellent case that showed complex ISR PCI. Is this case named TAT and right? I think maybe V stent technique was done if LAD stent is placed at LAD Os or only single stent at just approximate LCX Os. If I am wrong, send me the mistake points.
  • Se Hun Kang 2016-06-20 Thank you for good comment. On uploaded angiography, it looks like V stenting technique. But, on another view, there was small protrusion of LCX and LAD stents into the distal LM and rewiring of LCX was done through stent strut of LAD. So it would be better name TAP technique than V stenting.
  • Ayman Tantawy 2016-07-06 Very good case. a technical question please, why did not you re-use the BMW in LCX for rewiring. Is there any point behind changing to choice PT.
  • Se Hun Kang 2016-07-06 Thank you for good comment. As you mentioned we could re-use BMW for rewiring of LCX. But, Choice PT wire, hydrophilic-coated polyemer sleeve and flexible body, is good for tortuous and resistant lesion like this case. So we choose the Choice PT wire for rewiring of LCX.

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