Case

LAD Lesion Involving Bifurcation and Ostium Treated with T-Stenting Technique Using Sirolimus-Eluting Stents

- Operator : Charles Chan

LAD Lesion Involving Bifurcation and Ostium Treated with T-Stenting Technique Using Sirolimus-Eluting Stents

- Operator: Charles Chan, MD, Wook-Sung Chung, MD,

Clinical Presentation

A 66 year old woman was admitted with effort chest pain for 20 days. Her coronary risk factor was hypertension. Baseline ECG showed T-wave inversion in anterior leads. Echocardiography revealed no regional wall motion abnormality and normal LV systolic function (EF =66%).

Baseline Coronary Angiogram

1. Left coronary angiogram showed narrowing at ostial?proximal LAD, which also involved bifurcation (Figure 1, Figure 2).
2. Right coronary angiogram was normal.

Procedure

A 7Fr sheath was inserted through the right femoral artery, and the left coronary ostium was engaged with an 8Fr EBU guiding catheter with 3.5§¯ curve. Two 0.014 inch BMW wires were inserted into the LAD and the first diagonal branch, respectively (Figure 3). A 2.75 X 18mm Endeaver stent was positioned at the first diagonal branch and deployed at 12 atm to 2.86mm (Figure 4, Figure 5). And then, a 3.50 X 18mm Endeaver stent was positioned at the proximal LAD covering distal left main, and deployed at 12 atm to 3.59 mm (Figure 6, Figure 7). Following angiogram revealed significant narrowing at the diagonal ostium (Figure 8). Therefore, additional balloon dilatation was done with 2.5 X 15mm Sprinter balloon at 12 amt to 2.66mm (Figure 9). And then, ¡®kissing balloon post-dilatation¡¯ was performed at the LAD and the diagonal branch with 3.5 X 15mm Sprinter (at 6 atm to 2.87mm) and 2.5 X 15mm Sprinter (at 6 atm to 2.36mm) balloons, respectively (Figure 10). Final angiogram showed well-expanded stents without residual narrowing at both LAD and diagonal branch (Figure 11).
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Comments

  • Ricardo Lasevitch 2006-07-22 Nice case, congratulations. I have doubt if the diagonal ostium was completely covered and believe that ivus could be helpfull in this situation, showing the architecture of the bifurcation. A balloon with low pressure in LAD could not help to position the ostial diagoonal stent.
  • Alberto Hendler 2006-07-23 This bifurcation is a Y-shaped, therefore is not ideal for the modified T-stenting technique. In my opinion in this case the optimal technique could be "minimal crush" with final kissing balloon, using the two stages technique.
  • JAE-Sik Jang 2006-08-26 I agree with your opinion that crush technique with final kissing balloon could be a good alternative to T-stenting. Final result showed a good result without compromise of diagonal branch, and IVU was done showing full coverage of diagonal os. Thank you for your comments!

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