In-Stent Restenosis Lesion at LM Bifurcation

- Operator : Antonio Colombo

In-Stent Restenosis Lesion at LM Bifurcation
- Operator: Antonio Colombo, MD
Case Presentation
A 69 year-old female patient was admitted for abnormal CT and SPECT results. She had a history of diabetes mellitus and hyperlipidemia. She underwent percutaneous coronary intervention at LM bifurcation with crush technique 15 months ago. Xience Alpine 3.0 x 33 mm and 2.75 x 28 mm were deployed at LM to mid LAD, and Xience Alpine 3.5 x 18 mm was deployed at proximal LCX. The physical exam was normal. The ECG showed normal sinus rhythm. Echocardiogram showed normal left ventricular systolic function without definite regional wall motion abnormality. And thallium SPECT showed reversible large sized perfusion defect in anterolateral and inferolateral walls.
Baseline Coronary Angiogram & IVUS
  1. The Left coronary angiogram showed significant in-stent restenosis involving LM bifurcation stents. ( Movie 1, Movie 2)
  2. The right coronary angiogram showed diffuse mild stenosis involving proximal RCA. ( Movie 3)
Procedure
A 8 Fr sheath was inserted through right femoral artery and left coronary artery was engaged with a 8 Fr JL 4 guiding catheter. 0.014-inch BMW 190 cm wire was inserted into LCX and 0.014-inch BMW 190 cm wire was inserted into LAD. ( Movie 4) Pre-dilation was performed with a Powered Lacrosse 3.0 x 15 mm balloon. And a Flextome cutting balloon 3.0 x 10 mm balloon was used for calcified lesion and atheroma at LAD and LCX. ( Movie 5, Movie 6) Then, a Flextome cutting balloon 3.5 x 10 mm balloon was used for atheroma at proximal LAD. And then, two Pantera Lux 3.5 x 20 mm were used at LM to proximal LAD and LM to proximal LCX ISR lesions. Additional kissing ballooning was performed by using two Pantera Lux 3.5 x 20 mm balloons at LM bifurcation ISR lesions. ( Movie 7) Final angiogram ( Movie 8, Movie 9) showed that the procedure was successful.

Appendix
IVUS image of post ballooning ( Movie 10, Movie 11) of LAD and LCX

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