Slides Coronary Ostial
Left Main Coronary Artery Total Occlusion Intervention in a Patient with Right Coronary Artery Ostial Lesion Complicated by Subacute Stent Thrombosis
- Operator : Seung-Woon Rha
| Left Main Coronary Artery Total Occlusion Intervention in a Patient with Right Coronary Artery Ostial Lesion Complicated by Subacute Stent Thrombosis |
| - Operator : Seung-Woon Rha, MD |
| Clinical presentation |
| A 48 year-old woman visited our emergency room with typical sustained substernal chest pain for an hour. She had a history of hypertension and cerebral infarction. She suffered from effort chest pain with squeezing nature since 6 months ago. Initial ECG showed abnormal Q-waves in V1-3 and downslope ST depression in V 4-6 with marked elevation of CK-MB (69.8 ng/ml). Urgent 2D Echocardiography showed akinetic whole anterior wall and ejection fraction was 40%. |
| Baseline coronary angiogram |
CAG demonstrated total occlusion at the mid of left main (LM) coronary artery and moderate to severe stenosis in right coronary arery (RCA) ostium. Diffuse collaterals were visualized from RCA to proximal left anterior descending artery (LAD). (Figure 1, Figure 2, Figure 3) |
| Procedure |
Using a 7F JL4 guiding catheter and BMW wire from right femoral artery approach, successful wiring was done from totally occluded LM to distal LAD. Predilation was performed with Mercury 2.0 x 14mm (10 atm/ 10 sec) at the LM to proximal LAD. (Figure 4) Fortunately, whole left coronary artery system was visualized. (Figure 5, Figure 6) After dual wiring into LAD & LCX, 3 overlapping Taxus stents were successfully deployed from mid LAD to LM; Taxus 2.5 x 24 mm (16 atm/10sec), Taxus 2.75 x 16 mm (12 atm/10 sec), and Taxus 3.5 x 24 mm (14 atm/10 sec). (Figure 7, Figure 8, Figure 9, Figure 10) After LM to proximal LAD stenting, the ostium of LCX was significantly jailed, and then that lesion was sequentially dilated with Ryujin 1.5 x 15 mm (18 atm/15 sec) and Mercury 2.0 x 14 mm (10 atm/10 sec). (Figure 11) Final sequential kissing balloon was done with Yangtze 3.0 x 15 mm (LM to proximal LAD, 12 atm/20 sec) and Mercury 2.0 x 15 mm (12 atm/25 sec). (Figure 12) Additional ballooning was done with Quantum Maverick 3.5 x 8 mm. (Figure 13) Final angiogram showed excellent patency in whole left coronary artery. (Figure 14, Figure 15) Post PCI IVUS finding showed well expanded stent. (Figure 16, Figure 17) Two days after the index procedure, patient developed acute ischemic chest pain and ECG change (ST depression in II, III, and aVF). CK-MB was elevated to 8.31 ng/ml. Emergency coronary angiography showed thrombotic total occlusion at the proximal LAD, showing subacute stent thrombosis with repeat NSTEMI. (Figure 18) After successful guidewire passage, simple sequential balloon dilation was performed with Stormer 2.0 x 15 mm (8 atm/10 sec) and Quantum 3.0 x 12 mm (18 atm/10 sec). (Figure 19, Figure 20) Reopro (Gp IIb/IIIa receptor blocker) infusion was started with the repeat PCI. Final angiogram showed excellent angiographic patency with good distal run-off from LM to distal LAD. (Figure 21) |
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