Simple Crossover is Easy and Enough for LMCA Lesion, in Case of Disease Free LCX Ostium : The Importance of IVUS-Guided PCI

- Operator : Seung-Jung Park

Simple Crossover is Easy and Enough for LMCA Lesion, in Case of Disease Free LCX Ostium : The Importance of IVUS-Guided PCI
- Operator: Seung-Jung Park, MD
Case Presentation
A 56-year old women was admitted with recurred effort chest pain for several months. She received DES for significant stenosis at proximal to middle RCA one year ago. Her coronary risk factors were hypertension and diabetes. Baseline ECG showed T wave inversion in anterior leads. Echocardiography revealed no RWMA and normal LV systolic function.
Baseline Coronary Angiography
1. Left coronary angiogram showed a significant narrowing at LMCA shaft and bifurcation and diffuse narrowing at middle LAD and distal LCX (Figure 1, Figure 2, Figure 3).
2. Right angiogram showed discrete narrowing at RCA ostium, but patent previous stented site.
Procedure
An 8Fr sheath was inserted through the right femoral artery, and the left coronary was engaged with 8Fr JL4 catheter. A 0.014 inch NEO¡¯s Soft wire was inserted into LAD and the same wire into LCX (Figure 4). With emphasizing the importance of the intravascular ultrasound (IVUS) exam before the procedure, we performed IVUS study to take accurate information about the lesion, especially for LCX ostium. The IVUS showed tightly stenosed LMCA and sparing of ostium of the left LCX artery with a little soft plaque. With confirming disease free LCX ostium, we planned to perform cross-over stenting the LCX without provisional guidewire to the LCX. First, the mid portion of the LAD was treated by a 3.0x33mm Cypher stent up to 16atm (3.15mm) without predilatation (Figure 5). The LMCA lesion was predilated with a 3.0x33 Cypher stent balloon up to 6atm (2.72mm) with sparing additional balloon (Figure 6). Then, a 3.5x28mm Cypher stent was deployed to the LMCA lesion (covering LM ostium and overlapping with mid LAD stent about 2mm) up to 16atm (3.72mm) (Figure 7, Figure 8). Despite there was good result on the final angiography (Figure 9), post-stenting IVUS study showed suboptimal result and the minimal cross sectional area of the LMCA was 4.0mm2. Therefore, we overdilated the LMCA stent with noncompliant 4.0x12mm Sprinter balloon up to 16atm (4.47mm) twice (Figure 10, Figure 11). Final angiography showed excellent result (Figure 12, Figure 13). The post-procedure IVUS showed cross-sectional area of the LMCA was 9.6mm2 and the LCX ostium was not compromised.
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