Kissing Stenting for Left Main Bifurcation Lesion with Two Cyphers

- Operator : Seung-Jung Park

Kissing Stenting for Left Main Bifurcation Lesion with Two Cyphers

- Operator : Seung-Jung Park, MD

Case Presentation
A 62 year-old man had complaints of progressive exertional angina and shortness of breath at minimal effort for 3 months. Diagnostic angiogram, performed in another hospital, showed unprotected left main bifurcation disease. Urgent bypass surgery was offered, but refused. His coronary risk factors included hypertension and cigarette smoking. Echocardiogram showed normal LV function without regional wall motion abnormality.
Baseline Coronary Angiography
1. The left main had tight stenosis at the bifurcation. (Figure 1, Figure 2). The RCA was normal.

2. Proximal reference vessel diameter was measured 4.3 mm with a lesion minimal lumen diameter (MLD) of 0.9 mm and a lesion length of 12.4 mm (%diameter stenosis= 79%) by QCA analysis. The MLD of distal reference vessel of LAD and LCX were 3.0 mm and 3.5 mm, respectively.

Intravascular ultrasound
IVUS examination showed the same findings to the coronary angiography. IVUS image showed tight stenosis at LMCA bifurcation (Figure 3, Figure 4). and big proximal and distal reference vessel (Figure 5, Figure 6).
Procedure
A 9 F sheath was inserted through right femoral artery and the left coronary was engaged with a 9 F EBU left catheter. Left main to LAD and LCX were wired with 0.014 F Flexi wire and 0.014 F Floppy wire, respectively. A 7 F Flexicut DCA device (3.5-4.0 mm) was advanced into the distal LMCA and LAD ostium. And then 5 cuts were made (Figure 7). Angiogram (Figure 8) and IVUS image (Figure 9) following DCA showed significant plaque reduction in distal LMCA and ostial LAD. Plaque burden was decreased from 92.5 % to 52.3 %. We planed to treat this lesion with Kissing stenting with two Cypher stents. The big proximal reference of distal LMCA lesion facilitates the Kissing stenting technique. Without post-DCA balloon dilatation, Kissing stenting was performed with two 3.0 mm x 18 mm Cypher stents in LAD and LCX, simultaneously (Figure 10). This was followed by post-dilatation of stents in LAD and LCX with stent balloons, sequentially . Finally, kissing balloon dilatation was performed with stent balloons . Final angiogram showed good result with minimal stent jail of intermediate branch (Figure 11, Figure 12). IVUS image showed new carina formation in distal LMCA lesion (Figure 13) and final CSA of ostiums of LAD (Figure 14) and LCX (Figure 15) were 6.28 mm2 and 5.27 mm2 respectively with good stent apposition.

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