Slides

Left Main Bifurcation Disease Treated by Simple Cross-Over Stenting

- Operator : Seung-Jung Park

Left Main Bifurcation Disease Treated by Simple Cross-Over Stenting
- Operator: Seung-Jung Park, MD
A 61 year-old woman was admitted with effort chest pain for 6 months. About ten years ago, she underwent PCI at mLAD, dLCX, pRCA and dRCA. Her coronary risk factors were diabetes mellitus and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=60%) without regional wall motion abnormality. Treadmill test and thallium test were not done.
Baseline Coronary Angiogram
1. A left coronary angiogram showed significant tight narrowing of distal LM bifurcation and patent stent at mLAD and dLCX ( Movie 1, Movie 2).
2. A right coronary angiogram showed patent stent at pRCA and dRCA ( Movie 3).
Procedure
An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 3.5 catheter with side hole. First, Kinetix 0.014-inch guidewire was inserted at LCX and BMW 0.014-inch guidewire was inserted at LAD. We performed IVUS examination to determine the treatment strategy for the distal LM bifurcation disease. IVUS showed minimal stenosis at LCX ostium (IVUS LCX Movie 4). Therefore, we intended to treat the lesion with simple cross-over technique. Predilatation was performed with a 2.5 x 20mm Black Hawk balloon at LM to pLAD (Figure 1). After predilatation, Promus Element stent 4.0 x 24mm was implanted at LM to pLAD (Figure 2). Thereafter, adjunctive post-stenting balloon dilatation using a 4.0 x 15mm Quantum balloon was performed at LM to pLAD. The following angiogram showed well-expanded stent. We checked LCX FFR, which was 0.93. Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).

Comments

  • XIN ZHAO 2011-08-07 Perfect the treatment strategy.The final angiogram showed the well-expanded stent. Do you postdilate LCX after cross over of LM- LAD stent? Is only check with FFR to ascertain LCx ostial flow is compromised? Thanks.
  • Won-Jang Kim 2011-08-07 We didn't touch the LCX ostium. Yes, we evaluated the FFR value of LCx to check the functional status, and we also did IVUS examination, which showed an adequate result.
  • cong hongliang 2011-08-13 very good results, congratulation. why you didn,t finish kissing ballon after cross over of LM-LAD stent? what is your thingking about?
  • Jianqiang Xu 2011-08-13 There's some haziness in the ostium of LCX, did you check it by IVUS? I totally agree with you not to perform FKB for this LM bifur, actually, there's no evidence showed any benefit from FBK, and even some study showed a trend of no FKB better than FKB.
  • Won-Jang Kim 2011-08-13 Thanks for colleagues' sincere comments. Yes, we did a IVUS examination for LCX ostium and revealed the stent strut crossed, not plaque as described below
  • khondker shaheed hussain 2011-08-16 thanks good technique, but without FFR can we perform it?
  • Marcelo Ribeiro 2011-08-27 Being stuck with provisional stent technique for the majority of bifurcation lesions in the last 9 years ( it is a matter of faith, i do not believe in crushing a stent as something ideal), I can not agree that a FKB would do any harm in this case. For sure the true purpose would be to do a little reorientation of the struts crossing the LCX ostium, and getting that one stent/ two vessels coverage that was largely studied in vitro during the last decade. Of course this is of utmost importance when you have a meaningful amount of plaque at the side branch ostium. For sure, you can not compare a FKB in provisional stenting with the one done after the crushing technique, for example. But I do not work routinely with IVUS, so I would appreciate any insights regarding this technical aspect of the case. Thanks!
  • ramasami nandakumar 2012-01-02 im not sure that the final result is acceptable especially when the vessel involved is large and abutting the LMS. in my humble opinion, A FKB was definitely warranted in this case! it would be interesting to know what this looks like now or if she has had any clinical symptoms.
  • Young-Hak Kim 2012-01-02 We do not routinely perform FKB after stent-crossover. In our analysis of LM cohort, FKB did not improve long-term angiographic or clinical outcomes. In spite of better angiographic apperance at post-procedure, late loss at the ostial LCX appeared to be greater than no-FKB.

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