Slides

Recanalization of Chronic Total Occlusion of Left Main Coronary Artery Ostium with Guiding Positioned Outside Origin of Left Main Coronary Artery

- Operator : Seung-Jung Park

Recanalization of Chronic Total Occlusion of Left Main Coronary Artery Ostium with Guiding Positioned Outside Origin of Left Main Coronary Artery
- Operator : Seung-Jung Park, MD
Case presentation
The patient was a 47 year-old male. He presented with effort chest pain for 5 months. Coronary risk factor included hypertension. His baseline ECG showed normal. Echocardiography showed normal LV function with focal akinesia of mid-lateral wall.
Baseline coronary angiography
1. Because of total occlusion of ostial LMCA, engagement at LMCA was impossible, and left coronary angiogram was obtained by good collaterals from RCA. Collaterals from RCA to LAD reached the distal left main including bifurcation (Figure 1, Figure 2).

2. Right coronary angiogram was normal (Figure 3).
Procedure
After both groin sites were punctured, an 8F Judkins guiding catheter was positioned at the origin of LM and a 5F Judkins diagnostic catheter was engaged into the origin of RCA. OTW system, usually useful for recanalization of chronic total occlusion, was not used because left guiding catheter was positioned outside LMCA due to lack of stump indicating LMCA ostium. 0.014inch shinobi guidewire was selected first to cross the lesion, but they did not advance easily. It took thirty minutes to cross the lesion with same guidewire. After the advancement of guidewire into LCX, correct positioning of the wire in the true lumen of distal vessel was confirmed by contra-lateral dye injection, predilatation with 2.5x20 mm balloon at 10 atm was performed from LM to LCX to facilitate guidewire passage into LAD (Figure 4). After predilatation, engagement of guiding catheter into left coronary artery was possible. And then, another guidewire, 0.014inch Choice PT wire, was inserted and steered into distal LAD (Figure 5). Following angiogram revealed mild stenosis of proximal LCX and diffuse diseased LAD from proximal to mid segment (Figure 6). And then, predilatation with 2.5 x 20 mm balloon was done at LM to proximal LAD and mid LAD at 14 atm and 6 atm respectively (Figure 7, Figure 8). Following angiogram showed moderate calcific stenosis at LM (Figure 9). And then, cutting balloon 3.0 x 10 mm was used to dilate the LM (Figure 10). After predilatation using cutting balloon, BX 3.0 x 18 mm stent was positioned from LM to proximal LAD and deployed at 14 atm (Figure 11). Adjunctive high pressure dilatation with 3.5 x 10 mm balloon underwent for angiographic optimization (Figure 12). Following angiogram showed good result of stenting site and mild narrowed LCX ostium in multiple projection (Figure 13, Figure 14). Thus balloon dilatation of LCX origin was not considered to be necessary. Remained mid LAD lesion was treated with Biodivysio 2.5 x 18 mm at 15atm.

Comments

  • Zh.Q. pang 2005-03-09 Dear Prof. Park: I have seen the case for some time and I think to say some word since I saw it. It is very difficult to say a word to express my thoughts. It is not only the techniques, but also the responsibility, the courage, the confidence. you are the first interventional cardiology in the world.

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