LM Trifurcation Lesion Treatment Guided by IVUS

- Operator : Seung-Jung Park

LM Trifurcation Lesion Treatment Guided by IVUS
- Operator: Seung-Jung Park, MD
Case Presentation
A 75 year-old gentleman was referred for the treatment of known LM disease. About one month ago, he visited another hospital because of effort-related chest pain. At that time, his treadmill test was positive at stage 2, and coronary angiogram showed distal LM trifurcation lesion. CABG was recommended to him, but he refused open heart surgery. His coronary risk factor was current smoking. The physical examination was normal. The ECG showed ST segment depression at lateral leads, but cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=69%) without RWMA.
Baseline Coronary Angiography
1. The left coronary angiogram showed significant stenosis at LM trifurcation lesion ( Movie 1, Movie 2, Movie 3).
2. The right coronary angiogram showed nearly normal RCA with collateral flow to LCA ( Movie 4).
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 three 0.014 inch BMW wires into LAD, LCX, and RI, respectively. Firstly, we performed intravascular ultrasound (IVUS) evaluation from LM to LAD, LCX, and RI respectively (Figure 1). LCX ( Movie 5) and RI ( Movie 6) ostia were relatively preserved at IVUS examination. So, we planned to deploy a stent at LM to proximal LAD with simple cross-over technique. Predilatation was performed using a TREK 2.5x15mm balloon (Figure 2). We deployed a Promus Element 3.5x38mm stent at LM to proximal LAD with additional balloon dilatations using stent balloon (Figure 3, Figure 4). After stenting, angiogram showed discrete narrowing of RI ostium ( Movie 7). So we checked the FFR value of RI to evaluate the functional significance. The FFR value of was 0.86. Final angiogram showed that the procedure was successful ( Movie 8, Movie 9).

Comments

  • Ricardo Arturo Quizhpe 2013-04-12 The initial angiogram looked as a difficult case, but a simple strategy of cross-over plus IVUS guidance and FFR evaluation will certainly obtain short and long term excellent results.
  • Chen 2013-04-20 I agree one stent strategy for this case,but disagree to finish the procedure without final balloons kissing! I think the long-term outcome of restenosis rate decided with immediate FFR data is unconviencible and lack of RCT....
  • Dr Joy Sanyal 2013-04-30 i agree that on initial angiogram looked complex because of the angles involved.the RI ostial pinch could it be a carina shift.what strategy would you recommend for those centres which do not have ivus.

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