Slides

Cypher Stents Implantation for Chronic Total Occlusion in Left Main Coronary Artery Bifurcation

- Operator : Seung-Jung Park

Cypher Stents Implantation for Chronic Total Occlusion in Left Main Coronary Artery Bifurcation
- Operator: Seung-Jung Park, MD, PhD, Young-Hak Kim, MD
Case presentation
The patient was a 60 year-old male. He presented with effort chest pain for 6 months. His coronary risk factor was smoking. His baseline ECG and echocardiography showed normal findings.
Baseline coronary angiography
Left coronary angiogram showed chronic total occlusion at the left main (LM) bifurcation with retrograde filling by collateral flow from the right coronary artery (RCA) (Figure 1, Figure 2).
Procedures
Reopro was administrated just before the procedure. An 8F JL 3.5 guiding catheter was engaged into the LM ostium and the RCA catheter was also cannulated for simultaneous bilateral contrast injections. A 0.014 inch Shinobi wire was successfully introduced into the left anterior descending artery (LAD) under retrograde angiographic guidance by contrast injection from RCA. Balloon dilatations were performed from the middle LAD to LM ostium with a Hayate balloon (1.5 x 20 mm at 6 atm) and a Classic balloon (2.5 x 20 mm at 10 atm) (Figure 3, Figure 4). A 0.014 inch Floppy wire was also introduced into the left circumflex artery (LCX) and balloon dilation was performed with a Maverick balloon (1.5 x 20 mm at 20atm) (Figure 5). After recannalization in the LAD and LCX, the antegrade left coronary angiogram showed significant residual stenosis in LM bifurcation with involvement of LAD and LCX ostium (Figure 6). Therefore, a Cypher stent (2.5 x 33 mm at 12 atm) was deployed first in the middle LAD lesion (Figure 7). Then, another Cypher stent (3.5 x 33 mm) was placed from LMCA to proximal LAD overlapping with previous implanted stent in the middle LAD. After then, we planned to kissing stenting for the LM bifurcation because the LM was relatively large compared to the LAD and LCX. Therefore, the other Cypher stent (3.0 x 23 mm) was placed from the LM to the proximal LCX with aiming for kissing stenting (Figure 8). The LM-LAD stent was deployed first at 12 atm and the LM-LCX stent deployment was followed at 12 atm (Figure 9, Figure 10). Subsequently, kissing balloon dilatation was performed at 18 atm either (Figure 11). Final left coronary angiogram showed TIMI 3 flow without any residual in-stent narrowing in LMCA and both branches (Figure 12, Figure 13).

Comments

  • SanjaySrivatsa 2004-07-12 Very elegant case with excellent result! I have three questions:(1)Was IVUS done to assess left main size and plaque burden in case of need for debulking prior to stenting? (2)What is your rule of thumb for determining feasability of kissing stent? I have found Dr. samin sharma's suggestion of proximal vessel size = 2/3 x sum of both distal vessel sizes very usefulto determine feasability for kissing stent.(2)If you had done a classic colombo crush stent technique--would you deploy first stent in LAD and crush from LCX or vice-versa. I think it is easier to gain reaccess if you deploy first in lad and crush using the lcx stent.I also feel that if lcx stent is deployed first followed by lad stent after reaccess of lad , a reverse crush of the lad stent may work elegantly also. Since you have a lot of experience with these techniques in the left main-do you feel there is greater merit to kissing stents or crush stents in the left main. Do you feel with drug eluting stents now that the long term results for this patient are at least as good if not better than perhaps LIMA arterial by pass surgery to LAD and vein graft to LCX. What do the surgeons feel about this in your institution? I appreciate there is not a lot of long term data to base our judgements on. thanks --i enjoy your site very much
  • Seung-Jung Park 2004-07-13 Thank you for your comments. We always try to use IVUS-guidance in LM intervention. Although, we do not have a firm data that IVUS-guiding stenting gains a superior long-term clinical results, it is very useful for strategy selection, optimal stent opposition, stent selection, etc. In this case, IVUS study was also done. The size of LM was above 5mm. Therefore, we thought that kissing stenting may be optimal for such a big proximal reference vessel. In stent-crush for LM bifurcation, I agree with your opinion. However, my concern is that the side branch with crushed stent may be dilated less than the other branch. Generally, LAD is more important than LCX in term of clinical impact. Therefore, we crush the stent in the circumflex artery in most of cases. In our experience, high pressure dilatation in the main vessel after crush facilitates the balloon delivery to the side branch. And we should select low-profile balloons first. As you suggested, study comparing the efficacy of DES with CABG should be done in near future.

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