Case

Antegrade approach a In-Stent Restenosis CTO lesion of LAD

- Operator : Etsuo Tsuchikane

Antegrade approach a In-Stent Restenosis CTO lesion of LAD
- Operator: Esuto Tsuchikane, MD

A 54 year-old man whose coronary risk factors include smoker, hypertension and prior history of MI presented with exertional chest pain. 5 years prior, he underwent PCI using one BMS in the proximal LCX and two BMS in the mid RCA. About 4 years ago, another two Cypher stents were deployed in the mid LAD and distal LCX respectively at another hospital. His ECG showed Q waves in anterior leads.

Baseline coronary angiogram

1. A left coronary angiogram revealed a diffuse stenosis in the proximal LAD, diagonal branch and total in-stent occlusion in the mid LAD segment.(Figure 1)
2. A right coronary angiogram showed patent previous mid RCA stents and the LAD distal to occulusion was filled retrogradely by right-to-left collateral flow.(Figure 2, Figure 3)

Procedure

The RCA was engaged with JR4 5Fr diagnostic catheter and left coronary was engaged with EBU 3.5 7 Fr SH guiding catheter. The ISR CTO of mid LAD was initially probed antegradely with a Fielder FC 0.014 inch 180cm supported by 1.25 mm * 10 mm Ryujin OTW balloon.(Figure 4) After placement of balloon at the origin of lesion, wire was changed to a Conquest pro 0.014 inch 180cm wire. After advance of proximal cap of occluded segment, wire was changed to Miracle 3.0 0.014 inch, alternatively. After successful passage of guidewire with OTW balloon cathter, the guide wire was changed into Fielder FC 0.014 inch 180cm and advanced across the occlusion site successfully.(Figure 5) The 1.25 mm * 10 mm Ryujin OTW balloon was used to predilation and withdrawn using Extension 0.014 inch 150cm wire. Several sequential balloon dilations with Quantum 2.75 mm * 20 mm and Maverick 2.0 * 20 mm were performed from distal LAD.(Figure 6) The angiogram in spider view showed severe stenosis of the diagonal ostium.(Figure 7) Another Fielder FC 0.014 inch 180cm wire was positioned into the diagonal branch. After the kissing balloon with Quantum balloon 2.75 mm * 20 mm for LAD and Maverick balloon 2.0 mm * 20 mm for diagonal branch, a PROMUS-E stent 3.0 mm * 28 mm was deployed from proximal LAD into LM(Figure 8) and adjunctive kissing balloon was done with Quantum balloon 2.75 mm * 20 mm and Maverick balloon 2.0 mm * 20 mm. A PROMUS-E stent 2.5 mm * 28 mm was deployed in the mid to proximal ISR segment of LAD with overlapping.(Figure 9) Subsequent angiogram revealed a dissection in the mid LAD and a small perforation of the distal septal branch into LV cavity.( Movie 1, Movie 2) Additional PROMUS-E stent 2.5 mm * 24 mm was deployed at the mid to distal LAD.(Figure 10) Post-dilation for the stent area was done and the final result was good.( Movie 3, Figure 11)

Comments

  • Joao Alexandre 2010-04-09 Im worried about what people are considering good results!!!!
  • David H.M Kao 2010-05-12 How about the result of perforation /cardiac tamponade ? Do nothing ?

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