PCI for Eccentric, Focal LM Shaft Stenosis with Coexistent LAD Ostial Lesion ; Cross-Over Versus LM Stenting Only? : The FFR-Guided Decision Making
- Operator: James R. Magoris, MD
Case Presentation
A 71-year old man was admitted with effort chest pain. Two months ago, he underwent primary PCI with Cypher stent for RCA infarct-related lesion at other hospital. His coronary risk factors were hypertension and diabetes. Echocardiography revealed focal hypokinesia of basal inferior wall. His thallium spect showed reversible, medium sized perfusion defect in LAD territory and fixed defect at basal inferior wall.
Baseline Coronary Angiography
1. Left coronary angiogram showed a significant, focal and eccentric narrowing at LMCA shaft and diffuse narrowing at LAD ostium to proximal LAD (Figure
1).
2. Right angiogram showed a patent RCA stent.
Procedure
A 7Fr sheath was inserted through the right femoral artery, and the left coronary was engaged with 7Fr JL3.5 catheter. A 0.014 inch Choice PT wire was inserted into LAD and another Choice PT wire into LCX (Figure 2). We performed IVUS study to take accurate information about the lesions. The IVUS showed focal, ulcerative and heavy plaque at the shaft of LMCA with a focal snow-man shaped lumen and sparing of ostium of the left LCX. The IVUS finding of ostial to proximal LAD revealed diffuse significant plaque burden, however the minimal CSA was 5.7§±. So, we decided to evaluate FFR of LAD segment for decision making of stenting for the LAD lesion (Figure 3). The FFR was 0.83 and decreased to 0.79 after intracoronary adenosine infusion. Referring to this FFR value, we decide to perform stenting for only LMCA, just proximal to LAD ostium. First, the ostial to distal LMCA was covered by a 4.0x12mm Taxus liberte stent up to 18atm (4.5mm) without predilatation (Figure 4). Despite there was good result on the angiography (Figure 5), post-stenting IVUS finding showed suboptimal result. Therefore, we overdilated the LMCA stent with noncompliant 5.0x13mm Quantum balloon up to 18atm (5.2mm) (Figure 6). Final angiography showed good result for LMCA with residual LAD lesion (Figure 7, Figure 8). The post-procedure IVUS showed cross-sectional area of the LMCA was 17.9mm2.
