Left Main Bifurcation Lesion Treated with Simple Cross-over and Final Kissing Balloon Technique

- Operator : Seung-Jung Park

Left Main Bifurcation Lesion Treated with Simple Cross-over and Final Kissing Balloon Technique
- Operators: Seung-Jung Park, MD, Jong-Young Lee, MD
Case Presentation
A 61-year-old woman was admitted for staged PCI at LM bifurcation lesion. One month ago, she visited to ER presenting resting chest pain. At that time, her ECG showed ST depression at inferolateral leads and cardiac enzymes were elevated. She was diagnosed as NSTEMI. Her coronary angiogram showed LM bifurcation lesion with severe three vessel diseases. We strongly recommended CABG to her. However, she refused open heart surgery. Therefore, we firstly fixed a proximal RCA lesion with a Resolute Integrity stent (3.5 x 22mm). Her coronary risk factors were hypertension, diabetes, and hyperlipidemia.
Baseline Coronary Angiogram
1. The left coronary angiogram showed severe LM bifurcation lesion with plaque ruptures and significant stenosis at distal LCX ( Movie 1, Movie 2).
2. The right coronary angiogram showed patent previous stent at proximal RCA ( Movie 3).
Procedure
A 5 and 8 Fr sheaths were inserted into left and right femoral arteries, respectively. A 0.014 inch Fielder FC wire with a Finecross 130cm microcatheter was introduced into the LCX and was exchanged into a 0.014 inch BMW wire. A 0.014 inch Shiniobi wire with a Finecross 130cm microcatheter was also placed into the LAD. After predilatation with a Maverick 2.0 x 20 mm balloon at LM to LAD, we observed slow flow. Therefore, we placed an IABP in the descending aorta through left femoral artery and started with 2:1 pumping and injected glycoprotein IIb/IIIa inhibitor (Abciximab) in a bolus dose. After stabilization, we performed intravascular ultrasound (IVUS) evaluations at the LM to LAD, and LCX, respectively. Because LCX ostium was relatively preserved at IVUS examination, we firstly deployed a Resolute Integrity stent 3.5 x 30 mm at the LM to LAD (Figure 1). After rewiring to the LCX with a 0.014 inch Choice PT wire and balloon dilation with a Mini Trek 1.5 x 12 mm at LCX ostium, we reevaluated the LCX with an IVUS. And then, we deployed a Resolute Integrity stent 3.0 x 26 mm at proximal to distal LCX (Figure 2). Additional balloon dilatations were performed at proximal to distal LCX using Maverick 2.5 x 20 mm and Empira NC 3.0 X 20 mm balloons, sequentially (Figure 3, Figure 4). After dilatation with an Empira NC 3.5 X 20 mm at the LM to LAD (Figure 5), final kissing balloon dilatation was performed with an Empira NC 3.5 X 20 mm at the LM to LAD and a Maverick 3.0 X 20 (Figure 6). And then, after an IVUS evaluation, additional balloon dilatation was performed at proximal to distal LCX using an Empira NC 3.0 x 20 mm balloon (Figure 7). After that, we checked the FFR values of LAD and LCX using a pressure wire. The FFR values of LAD and LCX were 0.94 and 0.80, respectively. Final angiogram showed that the procedure was successful ( Movie 4, Movie 5). An IABP was removed.

Leave a comment

Sign in to leave a comment.