Repeat Kissing Stenting for Proximal Edge ISR after Kissing Stenting in Left Main Coronary Artery Stenosis

- Operator : Seung-Jung Park

Repeat Kissing Stenting for Proximal Edge ISR after Kissing Stenting in Left Main Coronary Artery Stenosis

- Operator: Seung-Jung Park, MD, Korea
Case presentation : Presented case in May 18, 2003
A 63-year old male patient underwent "kissing stenting" with two 3.0x18mm Cypher stents for left main (LM) bifurcation lesion 6 months ago (Figure 1, Figure 2, Figure 3, Figure 4). He was very happy with the result and no chest pain occurred during 6 months. He was admitted for a routine follow-up angiography.
Baseline angiography
Follow-up angiography was performed with a 5F Judkins catheter through the radial approach. Left coronary angiogram was shown in Figure 5, Figure 6. Unfortunately the proximal edge of the stents, ostial LM, appeared to be narrowed. The in-stent segments of both stents were perfectly patent.
Planned strategy
Although we recommended bypass surgery to the patient, he refused our medical advice. Therefore, we performed intravascular ultrasound (IVUS) first for complete evaluation of the edge restenosis lesion.
Procedure

A 7F sheath was inserted through right femoral artery and the left coronary was engaged with a 7F XB catheter. A 0.014 inch Floppy wire and a 0.014 inch Choice PT wire were inserted into the LAD and LCX, respectively. Because the wire could be crossed into the opposite stent through the overlapped stent strut in the LM, we tried to introduce a conventional balloon catheter and an IVUS catheter very carefully to verify proper positioning of the wires. After assuring the position of the two wires in the LAD and LCX, we obtained the IVUS images. IVUS image showed that the LM ostium was not covered with the two stents and had a tight stenosis with abundant plaque (Figure 7, from LAD to LM). The stented segments of the two stents were patent. By side-by-side comparison of the IVUS images at the index procedure and follow-up (Figure 8), we realized that the ostial LM with significant plaque was not covered with the stents at the index procedure and the stenosis was aggravated at follow-up. We intended to treat the lesion with repeat kissing stenting. After kissing balloon inflation (Figure 9), two 3.0x8mm Cypher stents were implanted with "kissing stenting" technique simultaneously (Figure 10). The result was very good (Figure 11, Figure 12). IVUS evaluation after procedure showed that the LM ostium was completely covered with the two stents. And the two stents were overlapped with the previously implanted two stents (Figure 13, from LAD to LM).

Comments

  • Jae-Hwan Lee 2003-10-26 Why don't you use only one stent to cover only LM ostial portion. If you dilate the LM-LAD in-stent portion first, the LM-LCx stent will be crushed. Additional kissing balloon will be possible. Then, you can treat LM ostial lesion with one bigger DES.
  • Cho Wook Hyun 2003-10-26
  • Seung-Jung Park 2003-10-27 First of all, ostium of left main is too big to cover the single drug eluting stent. And I don't want to have too much crushed metal in the let main shaft. Thanks for your comments.
  • Bon-Kwon Koo 2003-11-06 Angiographic results seem to be perfect, however, there are still quite a large amount of plaque at the ostium of left main trunk. What do you think about the debulking prior to stenting ?
  • Seung-Jung Park 2003-11-17 It was very controvertial point in the era of drug eluting stents. We have no soild data yet. However, we found some intriguing data about the frequency of late malapposition in the era of bare metal stent. The DCA prior to stenting had relatively higher frequency (10-11% vs 4.5% in control) of Late malappostion at IVUS follow-up study (unpublished data). Although we have also no data latemapposition of stents would be related with any adverse clinical events, we just speculated that combination of the two (DCA and drug eluting stent)might have some negative synergetic effect in terms of late malappostion of the stent. In any case, we didn't do DCA anymore in the era of drug eluting stents. Thank you for your advanced concerns.
  • Zhonghan Ni 2007-11-02 Dr Park:Can we get a conclusion that if IVUS is not avaiable,covering the ostium of LMCA in the index procedure may be a better strategy to treat any LMCA lesions? thank for your attention.

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