V Stenting Technique to Severely Calcified ISR Lesions in Trifurcation with Protected LAD

- Operator : Jung-Min Ahn

V Stenting Technique to Severely Calcified ISR Lesions in Trifurcation with Protected LAD
- Operator: Jung-Min Ahn, MD
Case Presentation
A 63 years old male patient visited to emergency department for chest pain during hemodialysis. He underwent CABG (LIMA to LAD, SVG to diagonal branch to PDA) 2 months ago. He also had history of prior PCI at LCX and RI 20 years before with BMSs. Because cardiac enzyme elevation was identified at the emergency department, he was hospitalized and underwent echocardiogram and coronary angiogram. Echocardiography showed reduced EF (49%) without regional wall motion abnormality, and CAG showed tight and calcified in-stent restenosis at trifurcation involving the LAD, LCX, and RI. As the LAD was protected with LIMA, we planned to treat LCX and RI lesions.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed diffuse and calcified stenosis with patent SVG to the diagonal branch to PDA flow. ( Movie 1)
  2. The left coronary angiogram showed diffuse calcified stenosis at trifurcation of the LAD, LCX, and RI. The LCX and RI was restenotic lesions of BMS stents. The LIMA to LAD was patent. ( Movie 2, Movie 3, Movie 4)
An 8 Fr long sheath was inserted through the right femoral artery and left coronary artery was engaged with an 8 Fr JL guiding catheter. The wire, 0.014-inch Fielder XT-R wire was inserted into the LCX with the help of Corsair micro-catheter. We decided to perform rotablation for heavily calcified stenotic lesion. A 0.014 inch Rotawire was inserted through corsair micro-catheter and stepwise rotablation was done with 1.5 mm burr. ( Movie 5) After rotablation, the diameter of the LCX ostium was bigger, therefore we checked IVUS at both LCX and RI, which showed severe ring calcified plaque on the previous stents. ( Movie 6, Movie 7) We planned to implant stents with V technique for the LCX and RI, because of discrepancy of the vessel size between LM and LCX or RI. We applied non-compliance balloon dilatation up to 28 atm (3.16 mm) at both LCX and RI several times to obtain enough space for subsequent stenting. (Figure 1, Figure 2, Figure 3) After kissing balloon, two Xience Alpine stents (3.0 x 15mm) were inserted to LCX and RI simultaneously to cover proximal edge ISR of both BMS stents. Finally, stents were deployed and final angiogram and IVUS showed optimal stent area without protrusion of stent strut into LM. ( Movie 8, Movie 9)

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