Hybrid PCI Using BVS and DES

- Operator : Duk-Woo Park

Hybrid PCI Using BVS and DES

- Operator: Duk-Woo Park, MD

Case Presentation

A 64 years-old gentleman was admitted with effort chest pain for a year. He had undergone coronary artery bypass grafting 2 years ago, and left internal mammary artery to LAD and saphenous vein graft to RI and PDA were made during operation. His coronary risk factors were hyperlipidemia and diabetes mellitus. The physical examination was normal. His baseline ECG and cardiac markers were unremarkable. Echocardiography showed a normal left ventricular ejection fraction of 55% without regional wall motion abnormality. Thallium scan showed reversible large sized perfusion defect in RCA territory.

Baseline Coronary Angiography

The left coronary angiography showed diffuse significant stenosis of left main, entire LCX and total occlusion of proximal LAD ( Movie 1). The LIMA to LAD and SVG to RI and PDA grafts were patent ( Movie 2, Movie 3). The right coronary angiogram showed diffuse significant stenosis from proximal to distal RCA ( Movie 4).

Procedure

A 7F sheath was inserted through right femoral artery, and the right coronary artery was engaged with a 7F AL1 catheter. 0.014-inch 190cm BMW wire was inserted into the distal RCA. We initially treat the lesion with application of full-BVS jacket, but IVUS image after pre-balloon dilatation (using Everest 2.5mm x 20 mm, Figure 1) showed disproportionally large vessel size of RCA ostium which cannot be dealt with the BVS (Figure 2, Figure 3). Therefore, we decided to treat the RCA with hybrid approach, namely, BVS-jacket for the available vessels with DES for the large ostial lesion. A total of three Absorb BVSs were deployed successfully at the distal (3.0 mm x 28mm), mid (3.5 mm x 28mm), and proximal (3.5mm x 28mm) RCA, respectively (Figure 4, Figure 5, Figure 6). Then Xience Alpine stent 4.0 mm x 28mm was deployed at the RCA ostium, subsequently (Figure 7). After high-pressure ballooning using NC TRECK 3.0 mm x 20 mm for the distal part and Empira NC 4.0mm x 15mm for the proximal part, final angiography showed excellent outcome (Figure 8, Movie 5).