Case

LAD and LCX ostial lesions with short LMCA treated by Kissing Stenting

- Operator : Yasutaka Yamauchi

LAD and LCX ostial lesions with short LMCA treated by Kissing Stenting
- Operator: Yasutaka Yamauchi, MD
Relevant clinical history and physical exam

A 65 year-old female was referred to our hospital because of unstable angina. She had received hemodialysis for 15 years because of DM nephropathy. Her coronary risk factors were diabetes, dyslipidemia, smoking, and hemodialysis.

Relevant catheterization findings

Coronary angiography showed short LMCA and severe stenosis of LAD and LCX ostium with severe calcification ( Movie 1, Movie 2). RCA angiogram showed no significant luminal narrowing ( Movie 3). We performed PCI for both LAD and LCX lesions because she rejected CABG.

Procedural step

Our strategy was kissing stenting for both LAD and CX lesions under IABP support because of short LMCA. 8F JL3.5 guide was chosen to prevent ostial injury. LAD was ablated using rotabar 1.25 and 1.5mm ( Movie 4, Movie 5). After gudewires were kept in both LAD and LCX, KBT was performed with Ryujin 2.5X15mm for LAD and Racross 2.5X15mm for LCX. Ryujin balloon was ruptured, and so, LAD was dilated with Racross balloon (Figure 1). Dissection was observed at distal seg6. Taxus 2.5X20mm was inserted to LAD enough to cover form LMCA to LAD dissection, and Taxus 2.75X16mm was placed form LMCA to LCX ( Movie 6). Both the proximal edges of stents was accurately positioned in LMCA ostium and both stents were simultaneously deployed. Max pressure was 22atm. Final angiogram showed good dilation of both LAD and LCXos ( Movie 7, Movie 8, Movie 9).

About 10 months later, she presented unstable angina again. Coronary angiography showed LAD ISR of 99% ( Movie 10, Movie 11). We recommended CABG, but she rejected it. And so, we performed PCI for LAD ISR under IABP support. 7F JL3.5 guide was engaged to LCA. Wiring to LAD was tough because of the risk that LAD wire was through the LCX stent strut. The finecross could reach the ISR proximal site, however, finecross could not cross the lesion. LCX was also wire-selected with GRANDSLAM. The ISR lesion was too tight or hard for finecross to cross. During balloon anchoring at LCX using 2.5X15mm Marveric balloon, Sprinter 1.25X10mm balloon could cross the lesion ( Movie 12). Unfortunately, Sprinter balloon was easily ruptured. Marveric 1.5X15mm was also ruptured. Racross 2X15mm could be dilated without balloon rupture and sizing up to Sprinter 2.75mm ( Movie 13, Movie 14). Finally, Cypher 3X13mm was deployed in stent of seg6 with the max pressure of 20atm during ballooning for LCX using 2.5mm balloon ( Movie 15, Movie 16, Movie 17). Final angiogram showed no residual stenosis at LAD stent ( Movie 18, Movie 19).

Comments

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