The IVUS and FFR Guided PCI in Short Discrete Ambiguous Stenosis

- Operator : Jin-sun Park

The IVUS and FFR Guided PCI in Short Discrete Ambiguous Stenosis
- Operator: Jin-sun Park, MD
Clinical Information

- Relevant clinical history and physical exam:
A 66-year-old female patient was admitted to our hospital for aggravating chest pain during 1 month. She had hypertension for coronary risk factor. At the time of admission, her blood pressure and pulse rate were 160/92mmHg and 82 beats per minute, respectively. The physical examination showed normal findings.

- Relevant test results prior to catheterization:
Initial ECG showed non-specific ST changes and echocardiography showed normal LV function without regional wall motion abnormalities.

- Relevant catheterization findings:
The coronary angiography showed three vessel disease with diffuse irregular 60~70% stenosis at the mid-portion of left anterior descending artery (mLAD, Figure 5), tubular irregular 77% stenosis at the distal portion of left circumflex artery (dLCX, Figure1) and discrete eccentric 80% stenosis at proximal portion of right coronary artery (pRCA, Figure 10).

Interventional Management

Procedural step:
A 7 Fr sheath was inserted through right femoral artery and the left coronary artery was engaged with a 7Fr EBU guiding catheter (Medtronic).
First, distal LCX lesion was dilated with Lacross 3.0x20mm balloon (Good man) at 6atm. (Figure 1, Figure 2) After that, Promus 3.0x18mm stent (Abbott) was implanted. (Figure 3) This lesion was dilated additionally with high pressure balloon (Fortis II 3.5x8mm) at 18atm. (Figure 4) Then, an intravascular ultrasound (IVUS) (Boston Scientific) was performed. IVUS showed 3.3 mm² minimal lumen area (MLA) at dLCX.
To evaluate the lesion of mLAD, IVUS was performed. IVUS showed 3.3 mm² MLA at mLAD. mLAD lesion was dilated with Lacross 3.0x20mm balloon at 16atm. (Figure 5, Figure 6) Promus 3.5x18mm stent was implanted to cover the pLAD lesion. (Figure 7) After adjunctive balloon with Fortis II 3.5x8mm at 22atm, (Figure 8) IVUS showed 9.5 mm² MLA. (Figure 9)
IVUS demonstrated discrete eccentric fibrocalcific plaque with web and 4.2 mm² MLA at pRCA. (Figure 10, Figure 11) After pressure wire (RADI) insertion, we checked FFR. (Figure 12) Baseline FFR was 0.98. Then we induced hyperemia by intracoronary adenosine 240mcg/kg/min infusion. After induction of hyperemia, FFR was 0.80. Then we checked FFR while pull-back of the pressure wire (RADI). FFR result showed sudden step-up from 0.80 to 0.98 at the pRCA lesion. However, in that FFR was 0.80, we decided to defer PCI for that lesion.

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