FFR Guided PCI on Left Main Bifurcation Disease; Simple Cross-Over Stenting

- Operator : Seung-Jung Park

FFR Guided PCI on Left Main Bifurcation Disease; Simple Cross-Over Stenting

- Operator: Seung-Jung Park, MD

Case Presentation

A 64 year-old gentleman was admitted with effort chest pain for five months. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=66%) without regional wall motion abnormality. The thallium SPECT showed reversible large sized perfusion defect at LAD territory and partial reversible medium sized perfusion defect at RCA territory. His coronary risk factors were hypertension, hyperlipidemia and current smoking.

Baseline Coronary Angiogram

Left coronary angiogram showed significant diffuse narrowing of LM shaft and discrete 50% stenosis of LAD ostium. ( Movie 1, Movie 2, Movie 3) A right coronary angiogram showed subtotal occlusion and ulceration of mid RCA ( Movie 4)

Procedure

We decided to treat mid RCA subtotal occlusion lesion by optimal medical therapy and to perform intervention at left main to LAD ostium. An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with a 7 Fr JL 5.0 catheter with side hole. Firstly, we advanced to LM shaft and LAD ostium with Sion 0.014-inch guidewire and implanted Orsiro stent 4.0 x 22, directly (Figure 1). Thereafter, post-stenting adjunctive balloon dilatation was done by Quantum 4.5 x 15 mm (Figure 2). After stenting, LCX ostium seemed to be narrowed ( Movie 5, Movie 6). IVUS was unable to pass the LCx ositum, so we checked FFR in order to determine additional whether or not to treatment the narrowed LCX ostium (Figure 3). FFR was measured from baseline 0.94 to 0.77 on 140mcg/kg/min of adenosine infusion. We advanced Sion 0.014-inch guidewire into the proximal LCX, followed by additional balloon dilatation with Lacrosse 2.5 x 15 mm at proximal LCX (Figure 4). After balloon angioplasty, FFR checked from baseline 0.98 to 0.94. On LAD pull-back IVUS images, there was no deformed or protruded strut at LCx opening, we did not perform kissing balloon. Final angiogram showed that the procedure was successful ( Movie 7, Movie 8).