Case

LM Trifurcation Disease Treated with V Stenting Technique and Kissing Balloon

- Operator : Seung-Jung Park

LM Trifurcation Disease Treated with V Stenting Technique and Kissing Balloon
- Operator: Seung Jung Park
Clinical presentation

A 46-year old woman was was suffered from effort-related chest pain for 1 month. So, She visited our hospital and got coronary angiography. Her coronary risk factor was diabetes mellitus. Baseline ECG showed no ST segment change. Echocardiography revealed no regional wall motion abnormality and normal LV systolic function. Other noninvasive stress testings were not done.

Baseline coronary angiogram

1. Left coronary angiogram showed 80% narrowing of distal LM, tubular 80% narrowing of pmLAD and diffuse 70 narrowing of pLCX (Figure 1, Figure 2). Bypass graft angiography showed total occlusion of LIMA to LAD, TRA to Diagonal and OM graft.
2. Right coronary angiogram showed diffuse intermediate lesions.

Procedure
A 8Fr sheath was inserted into the right femoral artery, and the left coronary ostium was engaged with a 8Fr JL guiding catheter with 3.5cm curve. A 0.014 inch Runthrough wire was inserted into the RI, a 0.014 inch BMW wire was inserted into the LAD and a 0.014 inch Runthrough wire was inserted into the LCX. IVUS study was done about RI, LAD & LCX lesions. IVUS findings revealed heavy plaque burden in the LCX os (Figure 3) and LAD os with relatively minimal plaque in the distal LM (Figure 4) and heavy plaque burden with encircled calcification in the mLAD bifurcation lesion (Figure 5). Initially we performed rotablation with rotablator 2.0 burr at mLAD bifurcation lesion (Figure 6). Mid LAD tight lesion was predilated with 3.0X20mm Pleon balloon and then Cypher select 3.5 X 33mm stent and Cypher select 2.75 X 18mm stent were deployed by V-stenting technique at distal LM to LAD and distal LM to LCX lesions respectively (Figure 7, Figure 8). And then we performed kissing balloon with 3.5 X 33mm stent balloon at dLM-LAD and 2.75 X 18 mm at dLM-LCX os respectively. Final left angiogram showed that the procedure was successfu (Figure 9).
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Comments

  • Min Jeon 2008-05-05
  • Debabrata Dash 2008-05-09
  • zhangjiao 2009-02-13
  • nishit arvind choksi 2012-03-23 at least in the view that you have shown, the trifurcation disease does not appear to be significant. post procedure the ramus is significantly narrowed
  • Bing Liu 2012-05-06 why did the last view show RI£¡After V-stent implantation£¬ RI os was jailed significantly.RI was not a small v.that can be igonored. And lastly, the pt underwent CABG? Nothing mentioned in presentation.the trifurcation lesion looked like all bordeline,was the stent necessary!?Why not FFR LCXos and LAD os!
  • Teh-Kuang Sun 2013-07-11 myocardial perfusion scan + FFR after CAG prior to PCI would be helpful to define to functional significant in relation to angina. The LAD-m lesion seems to be much more important to the LM trifurcation lesion. Beside, after V stenting, FFR to RI would be helpful to define if triple kissing balloon is indicated. After all, symptom and function dictates the need of PCI.
  • ahn jung min 2013-07-12 Thank you for your comments. FFR measurement is established physiologic index to evaluate the coronary stenosis. However, unforturnately, this procedure was done in 2008, when the FFR was not routinely measured in our cath lab. If we reviewed this procedures with FFR concept, FFR measurement for LM-LADos after mLAD stenting and jailed RI branch is necessary to decide the further appropriate treatment. According to the results, further treatment should be determined.

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