Slides

Proximal and distal stent edge ISR treatment using FFR assessment

- Operator : Seung-Jung Park

Proximal and distal stent edge ISR treatment using FFR assessment
- Operator: Seung-Jung Park, MD
Clinical history

A 50 year-old female was presented with effort-related chest pain for 2-months. 2-years ago, she had got PCI at pLAD with Cypher 3.5*18mm. After PCI, she had been stable but 2 months ago, she felt effort chest pain. She had medication including aspirin (Plavix for first one-year) and statin regularly for two years and she had no coronary risk factor. Her resting ECG was normal.
Baseline coronary angiogram

1. A right coronary angiogram showed intermediate stenoses in proximal and mid RCA. ( Movie 1)
2. A left coronary angiogram showed severe stenosis at proximal and distal edge of previous stent (Cypher 3.5 x 18mm) in pLAD, respectively. ( Movie 2)
Procedure

Left coronary artery was engaged with an 7Fr JL 4 guiding catheter with side holes. IVUS exam showed severe atherosclerosis at proximal and distal edge of stent with relatively normal in-stent segment between the two stenotic lesions. ( Movie 3) We planned to correct the LAD lesions because the FFR value in mLAD was 0.72 at maximum hyperemia with intravenous infusion of adenosine at 140mcg/kg/min. During maximal hyperemia, the pressure wire was slowly pulled back from the distal part of stent to the proximal part of stent. FFR value of distal part of stent was 0.72, in-stent was 0.76, proximal part of the stent was 0.98. (Figure 1) The △ pressure of stenosis at distal edge of the stent was 0.04 in FFR, and the △ pressure of stenosis at proximal edge of stent was 0.22 in FFR which was greater than that of distal edge of the stent. Therefore, we decided to treat the stenosis at proximal part of stent first. The proximal edge of stent at pLAD was treated with direct stenting (Xience V 3.5 x 15 mm). ( Movie 4) After correction of proximal stenosis, We measured again FFR to determine the functional significance of distal edge lesion. FFR value in mid LAD was 0.90. (Figure 2) We decided to defer the lesion of distal edge of stent and planned medical treatment. Final angiogram showed a good result with TIMI 3 flow. ( Movie 5)

Comments

  • Hisham 2010-12-11 A good teaching case but the lesion of the distal edge of the stent is also significant as the proximal one, so it was advisable to approach this lesion as well , since medical treatment is not a good option and it will not ameliorate the situation.
  • Seung-Jung Park 2010-12-13 THe meaning of FFR=0.90 was absolute abscence of ischemia. No doubt about it ! The reason why we deferred distal lesion even angiographycally significant (50-60%).
  • Joao Alexandre Farjalla 2010-12-16 Did you use FFR in the ostial CX lesion?
  • Erick Schampaert 2010-12-16 Dear S-J, This is an astute and most appropriate way to use FFR, allowing to limit the amount of new DES to be used. I am not certain of the excat physiological meaning of the pre-Re-PCI in-stent FFR measure (0.76), since few, if any branches seem present, in the stented segment, this situation is not a real tandem lesions situation, but maybe more a single continuous lesion. Yet, indeed, once you dilated the proximal, more severe stenosis, reassessing the FFR (provided you had no reflow which, as you know, could limit maximal hyperhemia, and therefore give a false high FFR value) did demonstrated the lack of need to intervene on the residual distal lesion. Congratulations!
  • Seung-Jung Park 2010-12-17 Hi! Erick, this case is one of typical "FFR guided spot stenting" cases, which we have recently gathered. Pijls NH and De Bruyne have already set up the basic concept of FFR in tandem lesions (Circulation 2000;101 and 102). In practical point of view, we made a simple mathematical formula (rule of big Delta) to define which lesion would be functionally more significant between the two serial stenosis. Just calculated the delta pressure from the absolute FFR value of proximal(Pa), mid(Pm) and distal portion(Pd). For particular this case, proximal delta pressure (Pa-Pm=0.22) was significantly bigger than that (Pm-Pd=0.04) of distal one, which meant proximal lesion would be functionally more significant. The reason why we treated proximal lesion first and reassessed the FFR. Based on our experiences (preliminary), we can save almost 40% of second stent. I agree with your concern about the possibility of false negative FFR after the first procedure, however, it would be not common. Thank you for your interest.

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