Suceessful PCI at Lt. Main Bifurcation ISR Lesion

- Operator : Young-Hak Kim

Suceessful PCI at Lt. Main Bifurcation ISR Lesion
- Operator: Young-Hak Kim, MD
Case Presentation
A 80 years-old gentleman was admitted through ER due to recently aggravated dyspnea. His coronary risk factors were hypertension, smoking. The chest x-ray showed mild pulmonary edema and moderate bilateral pleural effusion. The ECG showed poor R progression in V1~V2 lead. He was perfomed PCI at Lt.main bifurcation lesion by Drug-eluting stent 2 years ago.
Baseline coronary angiography
1. His left coronary angiogram showed diffuse significant In-stent restenosis at LM to proximal LAD. Another In-stent restenosis at proximal LCx was observed ( Movie 1, Movie 2).
2. The right coronary artery was nearly normal.
Procedure
At first, we inserted the IABP catheter through left femoral artery. An 8 Fr JL 4 guiding catheter with side holes was engaged at the left coronary artery ostium through right femoral artery. We inserted two 0.014 inch BMW wires into LAD and LCX, respectively. Predilatation was performed at LM to pLAD and LM to pLCx using a Ryujin 2.5x20mm balloon (Figure 1, Figure 2). Aditional predilation was performed at LM to pLAD with a 3.5x15mm NC balloon (Figure 3). We planned to deploy stent at LM to pLAD. A Resolute integrity stent 3.5x34mm was deployed at LM to pLAD (Figure 4). Following angiogram showed LCX ostium to pLCx was significantly stenosis. Thus, we dilated proximal LCX using a Ryujin 2.5x20mm balloon and Dura star 2.75x15mm balloon, sequentially (Figure 5).And then, we performed kissing ballooning with a Dura star NC balloon 3.5x15mm at LM to pLAD and a Dura star NC balloon 2.75x15mm at LM to pLCX (Figure 6, Figure 7). After that final kissing balloon dilation was performed with a Dura star NC balloon 3.5x15mm at LM to pLAD and Sequent please 2.75x20 drug eluting balloon at LM to pLCX (Figure 8). Final angiogram showed that procedure was successful ( Movie 3).

Comments

  • Mohammed Mohammed Al-Kebsi 2012-11-24 Well done and good results. whta is the prognosis of treating instent stenosis with Balloon only without stent?
  • Arash Gholoobi 2012-11-25 Nice result. Why didn't you use DEB at LM to LAD ?
  • Young-Hak Kim 2012-11-26 The lesion was not focal. The recurrent restenosis rate after balloon angioplasty for diffuse ISR is not good. Therefore, I put stents over the ISR lesions.
  • Kunal Bikram Shaha 2016-08-03 Sir why did not you prefer mini-cush rather than provisional stenting in this because the circumflex was bound to get jailed
  • Se Hun Kang 2016-08-03 Thank you for your comment. As shown in baseline angiography, there was diffuse in-stent restenosis at LM to proximal LAD and proximal LCX. So if we choose two stent technique, there would be the overlapping of four stents at LM bifurcation. It is a situation we want to avoid. Therefore we choose provisional stent at LM to proximal LAD and DEB at proximal LCX area.

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