LM Bifurcation Lesion Treated by Crushing Technique

- Operator : Seung-Jung Park

LM Bifurcation Lesion Treated by Crushing Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 75 year-old gentleman was referred for the treatment of known LM disease. About two weeks ago, he visited another hospital with resting chest pain. At that time, his coronary angiogram showed LM disease, and CABG was recommended to him. But he refused open heart surgery. His coronary risk factors were diabetes, hypertension, hyperlipidemia, and ex-smoker. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=56%) without RWMA.
Baseline coronary angiography
1. The left coronary angiogram showed significant stenosis at LM bifurcation lesion ( Movie 1, Movie 2).
2. The right coronary angiogram showed diffuse and significant stenosis at distal RCA ( Movie 3).
Procedure
An 8 Fr JL 4 guiding catheter with side holes was engaged at the left coronary artery ostium through right femoral artery. We inserted two 0.014 inch BMW wires into LAD and LCX, respectively. Predilatation was performed at LM to pLAD using a Black Hawk 2.5x20mm balloon (Figure 1). We also predilated at LM to pLCX with a Pantera 3.5x20mm balloon (Figure 2). Despite predilatation, angle between LM and proximal LCX was so acute and stent passing was not easy. So, we used a 5 Fr Heartrail catheter to cross over the lesion and deployed a Promus Element 4.0x12mm stent at LM-pLCX. Following crushing of LCX stent with a Ryujin 3.0x20mm balloon was performed (Figure 3). After that, we deployed a Promus Element stent 4.0x20mm at LM to pLAD (Figure 4). Additional balloon dilatations were performed at LM to pLCX using Maverick 1.5x15mm and TREK 3.0x15mm balloons, sequentially (Figure 5). After dilatation with a Pantera 3.5x20mm balloon at the LM to pLAD (Figure 6), final kissing balloon dilation was performed with a Pantera 3.5x20mm balloon at LM to pLAD and with a TREK 3.0x15mm balloon at LM to pLCX (Figure 7). And additional balloon dilatation was performed using Quantum 4.5x18mm balloon at LM (Figure 8). Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).

Comments

  • yu tao 2012-10-04 It¡®s a successful operation£¡As we can see£¬there are tight significant stenosis at the ostium of LAD and LCX¡£The strategy of crush reduces the risk of Jailed branch£¬superior to Culotte¡£For this operation details£¬Seung-Jung Park professor,could you tell us the release pressure of LCX stent£¿First£¬I have a question about post-dilation baloon at LCX if it¡¯s smaller TREK 3.0x15mm balloons £¬compared with Promus Element 4.0x12mm stent ¡£Second£¬The right coronary angiogram showed the ostium seems like tight stenosis¡£Is it spasm or plaque£¿In view of the age of patient£¬If the RCA shuold be treated by optimal medical therapy£¬ rather than stent¡£
  • Joao Alexandre Farjalla 2012-10-07 Very complex lesion and a nice result. Congrats!
  • Fahim Jafary 2013-03-18 As always excellent result. Is there any adverse effect of using a balloon only in the left main - LAD (the 4.5 x 18 mm balloon) AFTER you've done your final kissing balloon dilatation? Intuitively I would think not but don't know if this has been systematically studied.
  • yuexi wang 2013-04-11 very good! Congrates

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