Unprotected Left Main Stenting with Debulking for Focal Ostial Stenosis : IVUS guidance

- Operator : Seung-Jung Park

Unprotected Left Main Stenting with Debulking for Focal Ostial Stenosis
: IVUS guidance
- Operator : Seung-Jung Park, MD
Case presentation
Sixty-seven year old female presented with effort chest pain for five months. She had a hypertension as a coronary risk factor. Her baseline ECG showed normal. Thallium SPECT showed reversible perfusion defect in LMCA territory. Echocardiography showed good LV function with an EF of 63%.
Baseline coronary angiography
1. Baseline coronary angiogram showed LMCA ostial narrowing (Figure 1). QCA reference vessel diameter was measured 4.8mm with a lesion MLD (minimal lumen diameter) of 1.8mm (% diameter stenosis= 63 %) and a lesion length of 9.0 mm.

2. LCX and RCA were normal.
Intravascular ultrasound
Left main to LAD was wired with 0.014 Fr Flexicut wire. IVUS was performed through the wire. IVUS image showed the tight stenosis at LMCA ostium (Figure 2). Lesion EEM CSA (external elastic membrane cross sectional area) was 14.4mm2 and lumen CSA was 3.6mm2. Distal reference EEM CSA was 21.8mm2 and lumen CSA was 15.5mm2 (Figure 3). Degree of negative remodeling of LM ostium was about 34%.
Procedure
An 8F sheath was inserted through right femoral artery and the left coronary was engaged with an 8F EBU catheter. Left main to LAD was wired with 0.014Fr Flexicut wire. The 7Fr Flexicut directional coronary atherectomy (DCA) device (3.5-4.0mm) was advanced into the LMCA lesion, and 4 cuts were made. Post DCA angiogram is shown in Figure 4. During procedure, the vital sign was stable. There was no ECG change. Without post-DCA balloon dilatation, the LMCA was stented with a 4.5mm ¢¥ 13mm Bx stent with 12 atm (Figure 5) to cover the LMCA ostium. Final angiogram showed a good result with QCA measurement of LMCA MLD of 4.7mm (Figure 6). By IVUS image after procedure, lesion EEM was 19.9mm2 and final stent area was 13.3mm2 (Figure 7). IVUS showed that stent strut was protruded 3mm into the aorta.

Leave a comment

Sign in to leave a comment.