Slides Coronary Ostial
LM and LAD Bifurcation Lesions Treated by Double Crush Techniques under the Support of IABP in Patient with Severe Biventricular Failure
- Operator : Young-Hak Kim
| LM and LAD Bifurcation Lesions Treated by Double Crush Techniques under the Support of IABP in Patient with Severe Biventricular Failure |
| - Operator: Young-Hak Kim, MD |
| Case Presentation |
| A 50 year-old man visited to our ER complaining of dyspnea (NYHA class III-IV), cough, and sputum for about one month. There were relative tachycardia, crackle sounds on the lung field, and pretibial pitting edema on the physical examination. Chest X-ray showed mild cardiomegaly and marked vascular congestion on both lung fields. ECG showed poor R progression without definite Q wave and cardiac enzymes were normal. BNP value was 3186 pg/mL. Initial echocardiography revealed severe biventricular failure (EF=22%) with severe resting pulmonary hypertension (TR Vmax=4.1m/s). Thallium SPECT showed reversible large sized perfusion defect at LAD territory. His coronary risk factors were newly detected diabetes and ex-smoking. After stabilization with medical treatment, we performed coronary angiogram. After coronary angiogram, we strongly recommended CABG to him. However, he refused open heart surgery. Therefore, after discussion with him and his family, we decided PCI for the left coronary artery lesion. |
| Baseline coronary angiogram |
The left coronary angiogram showed significant stenosis at LM bifurcation and diffuse tight stenosis at proximal to mid LAD and diagonal branches ( Movie 1, Movie 2, Movie 3).The right coronary angiogram showed chronic total occlusion at proximal RCA ( Movie 4). |
| Procedure |
| 9 and 8 Fr sheaths were inserted into left and right femoral artery, respectively. Firstly, we placed prophylactic IABP in the descending aorta through left femoral artery and started with 2:1 pumping ( Movie 5). An 8 Fr XB 3.5 guiding catheter with side hole was engaged into left coronary artery ostium through right femoral artery. And then, we tried to insert a 0.014 inch BMW wire into LAD, but failed. Thus, we inserted a 0.014 inch Fielder FC wire into LAD using FINECROSS microcatheter, and then we changed Fielder FC wire into BMW wire. A 0.014 inch Fielder FC wire was inserted into diagonal branch using FINECROSS microcatheter (Figure 1). Predilatation was performed at diagonal branch with Maverick balloon 1.5x15mm (Figure 2) and at proximal LAD with IKAZUCHI balloon 2.5x20mm, respectively (Figure 3). After predilatation, we sequentially deployed Resolute Integrity stent 3.0x30mm at mLAD (Figure 4) and Resolute Integrity 2.5x22mm at diagonal branch (Figure 5). High pressure balloon dilatation was performed with Dura Star NC balloon 3.0x20mm at pmLAD (Figure 6). Another 0.014 inch BMW wire was inserted into LCX and a Resloute Integrity stent 3.5x18mm was implanted at pLCX (Figure 7). Following high pressure balloon dilatation was performed with Dura Star NC balloon 3.0x20mm at LM to pLAD (Figure 8). After kissing ballooning at pLAD with Dura Star balloon 3.0x20mm and at diagonal branch with IKAZUCHI balloon 2.5x20mm (Figure 9), we deployed a Resolute Integrity stent 3.5x30mm at LM to pLAD (Figure 10). And then, balloon dilatation was sequentially performed at diagonal branch with IKAZUCHI balloon 2.5x20mm (Figure 11) and at proximal LAD with Dura Star NC balloon 3.0x20mm (Figure 12). Following kissing ballooning was performed at pmLAD with Dura Star balloon 3.5x20mm and at diagonal branch with IKAZUCHI balloon 2.5x20mm (Figure 13). After balloon dilatations at pLCX with IKAZUCHI balloon 2.5x20mm (Figure 14) and at LM to LAD with Dura Star balloon 3.0x20mm (Figure 15), another kissing ballooning was performed at LM to pLAD with Dura Star balloon 3.5x20mm and at pLCX with Dura Star balloon 3.0x20mm (Figure 16). Finally, we stopped IABP and removed it. Final angiogram showed that the procedure was successful ( Movie 6, Movie 7). After PCI, patient’s condition and chest X-ray were markedly improved (Figure 17). |
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