Treatment of Diffuse Tandem Lesions of Left Anterior Descending Coronary Artery without Stent Overlapping

- Operator : Imad Sheiban

Treatment of Diffuse Tandem Lesions of Left Anterior Descending Coronary Artery without Stent Overlapping
- Operators: Imad Sheiban, MD, Jae-Sik Jang, MD
Case Presentation
A 52-year old gentleman was admitted for staged PCI at LAD lesion. About fourteen years ago, he underwent PCI at mRCA (Crossflex) due to STEMI. Two weeks ago, he visited to ER presenting resting chest pain, and was diagnosed as STEMI at inferior wall. Primary PCI was performed for distal RCA (Genous 3.0x28mm). At that time, left coronary angiogram showed diffuse tight stenosis at proximal to mid LAD. His coronary risk factors were hypertension, hyperlipidemia, and ex-smoking. Echocardiography showed normal LV systolic function (EF=60%) without RWMA. However, thallium SPECT showed reversible large sized perfusion defect at LAD territory.
Baseline coronary angiogram
The left coronary angiogram showed significant diffuse tandem lesions at LAD ostium to mid LAD ( Movie 1, Movie 2).
The right coronary angiogram showed patent previous stents (Crossflex and Genous 3.0x28mm) ( Movie 3)
Procedure
A 7 Fr XB 3.5 guiding catheter was engaged into left coronary artery ostium through right femoral approach. Two 0.014 inch BMW wires were inserted into the LAD and RI, respectively. They performed predilatation at pLAD and mLAD with a Dura Star balloon 2.5x15mm. And then they deployed a Promus Element stent 3.5x12mm for the distal LM to pLAD lesion (Figure 1). After post-stenting adjunctive balloon dilatation with a Powered Lacrosse balloon 3.0x15mm at LM to pLAD, they deployed a Promus Element stent 3.0x38mm for pmLAD lesion without stent overlapping (Figure 2). They performed post-stenting adjunctive balloon dilatation with a Powered Lacrosse balloon 3.0x15 mm. And then, they checked FFR value at RI using a pressure wire and FFR value was 0.80. After intravascular ultrasound evaluation from LM to LAD, they decided additional high pressure ballooning at distal LM to pLAD with a Quantum balloon 4.0x8 mm and at pmLAD with a Quantum balloon 3.5x8mm. Final angiogram showed that the procedure was successful ( Movie 4).

Comments

  • Arash Gholoobi 2012-06-27 I beleive ostial LAD stenting without crossing over into the LM could be feasible.
  • Jingjin Che 2013-12-12 Why was the prca was left ?
  • Young-Hak Kim 2013-12-16 RCA was a intermedate stenosis and did not require stenting. When the plaque burden was extended to the distal left main, the complete lesion coverage covering ostial LCX is important to avoid geographic miss in case of normal circumflex artery.

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