Slides

PCI for LM Trifurcation Lesion with Eccentric Heavy Plaque Burden and Calcification at Distal LM : Return of Debulking Atherectomy

- Operator : Seung-Jung Park

PCI for LM Trifurcation Lesion with Eccentric Heavy Plaque Burden and Calcification at Distal LM : Return of Debulking Atherectomy
- Operator: Seung-Jung Park, MD
Case Presentation
A 65-year old man was admitted with effort chest pain for several months. His coronary risk factors were hypertension and smoking. Baseline ECG and echocardiography were normal. Coronary angiogram showed significant distal LM trifurcation, diffuse middle LAD, diffuse distal LCX (not severe), and middle RCA narrowing. Two days ago, he received PCI with DES for RCA lesion (Figure 1, Figure 2).
Baseline Coronary Angiography
Left angiogram showed a significant distal LM trifurcation disease with eccentric heavy calcification and diffuse narrowing of middle LAD and distal LCX (Figure 3, Figure 4).
Procedure
An 8Fr sheath was inserted through the right femoral artery, and the left coronary was engaged with 8Fr EBU 3.5 guiding catheter. A 0.014 inch Choice PT wire was inserted into LAD, a 0.014 inch BMW wire into LCX, and a Choice PT wire into RI. We performed IVUS study to take accurate information about the lesions. The IVUS showed eccentric, heavy soft plaque with heavy calcification on the opposite site of the distal LM and calcified plaque on the left LCX ostium. Referring to the IVUS findings of the distal LM, we decided to perform directional coronary atherectomy (DCA) to facilitate successful stent placement and potentially reducing restenosis. After removal of previous catheter, 0.014 Flexicut wire was inserted into LAD. Then, debulking atherectomy was performed at distal LM with Flexicut 3.5-4.0mm atherectomy catheter device (Figure 5). After confirming satisfactory angiographic result of debulking atherectomy (Figure 6, Figure 7), a 3.5x28mm Cypher select stent was placed from LM to proximal LAD covering LM ostium and cross-over LCX (Figure 8, Figure 9). Despite there was relatively good result on the angiography (Figure 10, Figure 11), post-stenting IVUS findings showed suboptimal result. Therefore, we overdilated the LM stent with a 4.0x20mm Ryujin balloon up to 16atm (4.46mm) (Figure 12, Figure 13). IVUS evaluation about LCX ostium revealed that there was no significant plaque shift after cross-over the LCX (Figure 14). Final kissing balloon dilation was performed with a 3.5x20mm Black Hawk balloon for LAD and 3.0x20mm Sprinter balloon for LCX (Figure 15, Figure 16). The final angiogram showed that the procedure was successful (Figure 17, Figure 18).
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Comments

  • Takashi Okada 2007-05-04 DCA is sometimes regarded outdated device in the museum. But if the plaque distribution is perfectly evaluated, (In this case, Dr.Gary S. Mintz, was the IVUS commentator) it works nicely. DCA is in danger of extinction. But this case showed that debulking contributed to the avoiding of plaque shift. More sophisticated debulking devices will be the next solution of bifurcation lesions. Takashi Okada, Kyoto First Redcross Hospital , Japan.
  • Zhonghan Ni 2007-11-04 Dr Park:What was your initial planed strategy with three wires? I always question the method that overdilate the Cypher 3.5mm to excess 4.5mm diameter,whether the Cordis technicians provided relevant data? Iam very sincerely appreciated to be explained!

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