Left Main Disease with Distal RCA CTO Lesion

- Operator : Seung-Jung Park

Left Main Disease with Distal RCA CTO Lesion
- Operator: Seung-Jung Park, MD
Case Presentation
A 66 year-old gentleman was referred to our hospital for further evaluation of coronary CT abnormality detected on routine check-up. His coronary risk factors were hypertension and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=59%) without regional wall motion abnormality. Treadmill test was positive at stage 4 and thallium test showed large reversible perfusion defect of LAD and RCA territory.
Baseline Coronary Angiogram
  1. A left coronary angiogram showed significant luminal narrowing of distal LM to middle LAD and discrete but tight stenosis was observed at D1. And there was a grade 2 collateral flow from LAD and LCX to distal RCA. ( Movie 1, Movie 2, Movie 3)
  2. A right coronary angiogram showed total occlusion at distal RCA with grade 2 bridging collateral flow. ( Movie 4)
Procedure
A 7 Fr sheath was inserted through right femoral artery, and the right coronary artery was engaged with a 7 Fr AL2 SH guiding catheter. 0.014-inch 1.8 Fr 130cm FINECROSS micro-guide catheter with NEO¡¯s (Fielder XT) 0.014-inch 190 cm wire was inserted into the RCA. FINECROSS was delivered and Fielder XT was exchanged into BMW 0.014-inch 300 cm. Predilation was performed with Maverick 1.5 x 15 mm balloon and TREK 2.5 x 20 mm balloon at distal RCA to PL branch and PDA (Figure 1, Figure 2). And then, XIENCE Xpedition 2.5 x 38 mm was successfully deployed at distal RCA to PL branch (Figure 3). The following coronary angiogram showed well expanded stent at distal RCA with good distal run-off flow without any complication ( Movie 5).
For LM-mLAD lesion, as FFR also revealed 0.68, we decided PCI. 0.014-inch 190cm BMW guidewire was inserted into the Diagonal branch. Diagonal branch was pre-dilated with 1.5 x 15 mm Maverick balloon (Figure 4). And then, we pre-dilated LM to middle LAD using 2.0 x 15mm Maverick balloon (Figure 5, Figure 6). A XIENCE Xpedition 2.5 x 23 mm was successfully deployed at diagonal branch (Figure 7) and then another XIENCE Xpedition 3.25 x 38 mm was successfully deployed at LM to middle LAD by Crush technique (Figure 8). Additional kissing ballooning was performed by using an Empira NC 3.0 x 15 mm at proximal to middle LAD and Maverick 2.0 x 15 mm at diagonal branch (Figure 9). And additional NC balloon was done at LM-pLAD by Nimbus Salvo 3.5 x 13 mm for optimization. Final angiogram and IVUS showed that the procedure was successful. ( Movie 6, Movie 7)

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