Two Long Cypher Stents Implantation for Very Long LAD Lesion : Negligible Late Loss at Follow-Up Angiography and IVUS Examination

- Operator : Young-Hak Kim

Two Long Cypher Stents Implantation for Very Long LAD Lesion : Negligible Late Loss at Follow-Up Angiography and IVUS Examination

- Operator: Young-Hak Kim, MD, Korea / Seung-Jung Park, MD, PhD, Korea
Case presentation
A 55 year-old female presented with chest pain upon effort for 2 years. She had a hypertension as a coronary risk factor. The EKG revealed a T inversion on V4-V6. The echocardiography showed a LV ejection fraction of 56% with hypokinetic wall motion abnormalities in the LAD territory.
Baseline coronary angiography
1. Coronary angiogram showed a diffuse LAD stenosis with a subtotal occlusion distal to an outgrowth lesion of the middle LAD. (Figure 1, Figure 2).
2. The LCX and RCA were normal.
Procedure
A 7F sheath was inserted through the right femoral artery and the left coronary was engaged with a 7F Judkins catheter. An attempt was made to cross the lesion with a 0.014 inch Floppy guidewire. However, it could not be crossed at the occlusive lesion of the middle LAD. A stiffer wire, a 0.014 inch Shinobi wire, was used instead through an over-the-wire system in order to cross the lesion. In order to protect the side branch, another wire was also inserted to the diagonal branch. The distal flow of the LAD worsened after the wire advancement (Figure 3). Therefore, a predilation was performed in the tight lesion of the middle LAD (Figure 4). After repeated predilations in the LAD lesion, the blood flow of the LAD became better with multiple dissections (Figure 5). The diagonal branch was also predilated with a conventional balloon (Figure 6, Figure 7, Figure 8). Subsequently two 3.0mmX33 mm Cypher stents were sequentially implanted for the distal and middle LAD lesions (Figure 9, Figure 10). The in-stent lesion was dilated to 3.3 mm at 20 atm. The final angiogram showed a good result with a TIMI 3 flow (Figure 11, Figure 12).
During the follow-up period, she reported that she was very happy with the result and had no cardiac complaints. At 6-month follow-up angiography, the distal part of the stented segment appeared to be narrowed (Figure 13, Figure 14). However, the IVUS image showed that the narrowing was caused by an under-expansion of the stent due to severe calcification of the lesion (Figure 15) with a negligible amount of intimal growth.

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