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LM Bifurcation Intervention with Crush Technique
- Operator: Jung-Min Ahn, MD
Case Presentation
A 58-year-old male with prior history of CABG history was admitted for dyspnea on exertion. He underwent CABG with LIMA to LAD, and tRIMA to diagonal to OM to PDA sequential. Physical examination and a simple chest radiograph were unremarkable. Echocardiogram showed normal LV systolic function with hypokinesia of LCX territory.
Baseline Coronary Angiogram
  1. The left coronary angiogram showed diffuse 70% stenotic lesion at LM and both ostium of pLAD and pLCX (Figure 1, Movie 1).
  2. The right coronary angiogram showed total occlusion of pRCA.
  3. The LIMA angiogram showed good patency and a sequential RIMA graft with good flow to PDA, but not to diagonal and OM (Figure 2).
A 8 Fr femoral sheath was inserted through the right femoral artery and left coronary artery was engaged with a 8 Fr JL 4 guiding catheter. Each two 0.014-inch Sion 180 cm wires were inserted into LAD and LCX, respectively. After using NC balloon, IVUS was used to identify lesion characteristics of LAD and LCX. Two Resolute Onyx stent (2.75 X 22 mm at pLCX to OM and 2.75 X 26 mm at LM to pLCX) were deployed, and thereafter the stent at LM to pLAD (Resolute Onyx 3.5 X 22 mm) was inflated, so the proximal strut of the former was crushed. NC Emerge balloon sized 2.5 x 15 mm was used to dilate stenotic lesion of pLCX, and so was Raiden 3 sized 4.0 x 15 mm for stenotic lesion of LM to pLAD. IVUS was checked, and POT and kissing balloon were applied using Raiden 3 4.0 (15) upto 8atm (3.83) and stent balloon 3.5 (22) upto 8 atm (3.15) in LM-pLAD and LM-pLCX, respectively (Figure 3). Next, the 0.014-inch Fielder XT 190 cm wire was used to cross the diagonal branch. Following deployment at pLAD to diagonal with Resolute Onyx stent 2.5 x 38 mm, we changed Fielder XT wire to BMW 190 cm wire and used Guide zilla to pass another stent due to severe tortuosity and calcification. The fifth Resolue Onyx stent 2.25 x 22 mm was deployed with overlap at diagonal branch. The final angiogram showed no stenotic lesion and good flow ( Movie 2), and IVUS showed no immediate complications.
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