Slides

Proximal LAD Bifurcation Lesion Treated with Simple Cross-Over Technique

- Operator : Seung-Jung Park

Proximal LAD Bifurcation Lesion Treated with Simple Cross-Over Technique
- Operators: Seung-Jung Park, MD, Young-Hak Kim, MD
Clinical presentation
A 62-year-old man had admitted with effort chest pain for 6 month. Since last months, he suffered from crescendo chest pain. ECG showed non-specific finding, and biomarker was within normal range. Echocardiography showed normal LV systolic function (EF = 66%).
Baseline coronary angiogram

1. Left coronary angiogram showed significant tight narrowing of proximal LAD and diagonal true bifurcation site. Left main coronalry artery shows huge big diameter.(Figure 1, Figure 2, Figure 3).
2. Right coronary angiogram was normal

Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8F JL catheter with 4.0 cm curve. 0.014 inch BMW wires were inserted into the LAD and the D1 (Figure 4). Initially, mid LAD were predilated with 2.5 X 20 mm Apollo balloon and then 2.75 X 23 Cypher stent were implanted at mid LAD (Figure 5, Figure 6). Sequentially, 3.5 X 23 Cypher stent were implanted at proximal to mid LAD with overlapping previous stent (Figure 7). We checked FFR by intracoronary adenosine bolus infection. The values were 0.90/0.77 pre/post adenosine injection, respectively. According to FFR results, kissing balloon was performed between proximal LAD with 3.5 X 20 Dura star and diagonal with 2.0 X 20 Apollo balloon (Figure 8). After kissing balloon, we checked FFR again. The post-stent FFR values were 0.98/0.93 pre/pos. Final angiogram showed a well-expanded stents without residual narrowing (Figure 9, Figure 10).

Comments

  • Bambang Budiono 2009-06-19 Awsome result ! is FFR guided PCI routinely done in every cases in your Lab ?
  • Antonia Anna Lukito 2009-06-21 Wonderfully done..., could you provide the pressure values (atm) for each balloon dilation and stent implantation as well?
  • Seung-Jung Park 2009-06-22 Recently, we have prospective randomized study protocol regarding the bifurcation PCI. According to the protocol, we have FFR in almost all cases. For particulat this case, we had applied high pressure (25 atm) in main vessel LAD and 8-10 atm for kissing balloon inflation.
  • Bambang Budiono 2009-06-22 Thank you Dr. Park. As low FFR has been known as a strong predictor for instent restenosis and other CV event as well, do you think this functional modality is more useful compare to IVUS in complex lesion, such as bifurcation lesions ? Do you make a comparison between the 2 modalities in your study ?
  • Seung-Jung Park 2009-06-23 We have simultaneous measurement of FFR and IVUS in our study protocol. We are giong to have some answer in near future.
  • Bambang Budiono 2009-06-23 Interesting study. Looking forward to hearing the result.
  • Marcelo Ribeiro 2009-06-27 Since you put a guidewire in the diagonal branch this technique would be more like the provisional approach,which, in this simple bifurcation case, has an astonishing high level of sucess.Do you think that more complex cases could be more demanding for the pressure wire or your perception is that it has now a peformance close to a regular wire? Thank you for the great work!
  • Seung-Jung Park 2009-06-29 Depending on the lesion characteristics (vessel size, degree of compromise), sometimes we prefer pressure wire sometimes not. We have much more concerns about the kissing balloon inflation to be mandatory or not in all cases.
  • Yi Luo 2009-08-02 Good work. Do you usually apply extremely high pressure such as 25 atm in this case in main vessel for final kissing balloon inflation? Is it safe? Thank you.
  • Seung-Jung Park 2009-08-03 No!! we have used sequential high pressure inflation first. And for the kissing balloon inflation we have applied simulataneous moderate pressure with 8-10 atm in both balloon.
  • Fadili 2009-09-15 Great job Dr. Park, excellent result. Why exactly 8F? Did you use IVUS in this case?
  • Seung-Jung Park 2009-09-16 For the complex procedurelike this case, we prefer large lumen guider (8F) . When we have to do 2 stents procedure simultaneously, it should be more easier to do. "Big surgeon, Big incision"^^. For bifurcation intervention, we have prospective randomized study protocol. It includes IVUS, and FFR study before and after the procedure if possible.

Leave a comment

Sign in to leave a comment.