Left Main Coronary Artery Bifurcation Stenosis with Diminutive LCX, Treated with Stenting Alone

- Operator : Shigeru Saito

Left Main Coronary Artery Bifurcation Stenosis with Diminutive LCX, Treated with Stenting Alone

- Operator : Shigeru Saito, MD

Case Presentation
The patient was 64 year-old male admitted with exertional chest pain for 1 month. His coronary risk factor was hypertension. His baseline ECG showed T inversion in V1-V3. Echocardiography showed good left ventricular function with an ejection fraction of 75%.
Baseline Coronary Angiography
1. Left coronary angiogram showed LMCA bifurcation lesion without involvement of ostial LAD (Figure 1, Figure 2). LCX was relatively small and the ostium was normal. Proximal reference vessel diameter was measured 4.2mm with a lesion MLD of 1.5mm and a lesion length of 10.0mm by QCA analysis. The MLD of distal reference vessel (LAD) was 4.9 mm. The diameter of proximal LCX was measured 2.5 mm.

2. Right coronary artery was normal.
Intravascular ultrasound
IVUS image showed large soft plaque burden at LMCA bifurcation (Figure 3). Inside the soft plaque, the low echogenic area implying lipid core was shown at 10 o'clock (Figure 4). The lesion EEM (external elastic membrane) diameter and area were measured 5.17 mm and 18.99 mm2, respectively. The ostiums of LAD and LCX were not narrowed significantly (Figure 5).
Procedure
Before IVUS examination, we planned the DCA followed by stenting for LMCA bifurcation lesion. Therefore, a 9 F sheath was inserted through right femoral artery and the left coronary was engaged with a 9 F EBU catheter with 3.5cm curve. Left main to LAD was wired with a 0.014 F Flexi wire. After IVUS examination, we concluded that DCA was not necessary. It was because the soft plaque containing lipid core could be dilated well with stenting alone and was likely to have high rate of periprocedural complications after DCA. Therefore, we changed treatment strategy with stenting alone. Predilation was performed to facilitate the passage and positioning of the sent maintaining blood flow to distal coronary artery (Figure 6). Then a 5.0 mm x 12 mm Express stent was deployed in the distal LMCA crossing over the ostial LCX (Figure 7). Following angiogram showed very good result without occlusion of the LCX ostium (Figure 8, Figure 9). IVUS image also showed good result with a final stent CSA of 15.36 mm2 (Figure 10).

Leave a comment

Sign in to leave a comment.