Treating In-Stent Restenosis of Kissing Stent in Left Main Bifurcation with Drug-Eluting Stent Resulting in Incomplete Crushing

- Operator : Ki Bae Seung

Treating In-Stent Restenosis of Kissing Stent in Left Main Bifurcation with Drug-Eluting Stent Resulting in Incomplete Crushing

- Operator: Ki-Bae Seung, MD, Pum Joon Kim, MD

Clinical Characteristics

A 60-year-old female patient was admitted with chest pain for 2 month. Her risk factors were hypertension and diabetes mellitus. Baseline electrocardiogram indicated normal sinus rhythm without ischemic changes and echocardiography showed normal left ventricular function (EF=55%) without regional wall motion abnormality.

Baseline Coronary Angiogram

1. Left coronary angiogram showed the distal left main (LM) bifurcation lesion involving proximal left anterior descending (LAD) and proximal circumflex artery (LCX) (Figure 1 and Figure 2).
2. Right coronary angiogram showed normal finding.

Procedure

Index Procedure

An 8 Fr sheath was inserted into the right femoral artery and the LM artery was engaged with an 8 Fr Judkin guiding catheter. The LAD was passed with a 0.014 inch Asahi wire and the LCX was passed with a 0.014 inch BMW wire (Figure 3). The LCX was pre-dilated using Apollo balloon 2.5X15 mm upto 8 atm (Figure 4). Simultaneous kissing steniting was done with Cypher 3.0X18 mm upto 16 atm for LAD lesion and Cypher 3.5X18 mm upto 18 atm for LCX lesion (Figure 5 and Figure 6). Kissing balloon was inflated simultaneously with stent balloon 3.0X18 mm upto 6 atm for LAD stent and 3.5X18 mm upto 6 atm for LCX stent (Figure 7). Final angiogram showed good postprocedural results without residual stenosis or dissection (Figure 8 and Figure 9).

Target Lesion Revasuclarization

Four months later, she suffered from effort chest pain with positive result on treadmill test. Follow-up angiogram showed an in-stent restenosis about 95% on LCX ostium in kissing stenting (Figure 10 and Figure 11). A 0.014 inch Asahi wire was advanced into the LAD and a 0.014 inch BMW wire into the LCX (Figure 12). The LCX ostium was dilated with Maverick 3.0X15 mm balloon (Figure 13) and then kissing balloon was done with Terumo 3.0X15 mm balloon at LAD upto 6 atm and Maverick 3.0X15 mm balloon at LCX upto 6 atm (Figure 14). Intravasuclar ultrasound showed the LCX wire making its way into the LCX stent by passing through the wider LAD stent instead of the narrowed LCX stent. In conclusion, our procedure resulted in incomplete crushing of the LCX stent (Figure 15 and Figure 16).

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Comments

  • christopher wong 2006-09-30 In figures 1 and 2, it didn't appear that the LAD lesion was critical. Would it be a better approach to stent the circumflex artery only in the first place, using the "stopper technique" instead of simultaneous kissing stents (SKS) technique? Dr. Wong
  • Seong-Wook Park 2006-10-02 Comment on Dr. Wong's opinion; If only the circumflex had been treated with DES, re-intervention would have been simpler. But, I think you can hardly intervene Cx alone without compromising LAD ostium, considering plaque shift or overhaning of the stent struts across LAD. Dr. Seung presented a beautiful case of simultaneous kissing stenting at LM and also showed the potential diificulties of reintervention in case of restenosis after Kissing stenting. In terms of feasibility of re-intervention, initial Crushing technique must have advantages over SKS.
  • 박성훈 2006-10-14 I think wire path must have been checked with IVUS before balloon inflation.
  • Pete Beglin 2007-07-17 I share Dr. Park's opinions that reintervention on SKS is the most difficult, and that isolated LCx stenting initially would not have sufficed. However, although we tend to never want to jail the LAD, the burden of disease in the LAD at baseline was small enough that "crossover" from the left main to the LCx with kissing balloon jailbreak of the LAD, with bailout T stenting if necessary, was perhaps an option. I used to SKS this morphology, but as the data progresses, I have switched to crossover with a kiss. I would suggest serial angiography in follow-up for this lady, given that her risk of recurrent restenosis is quite high, and left main restenosis may be a malignant process.
  • Zhonghan Ni 2007-11-04 good case,wonderful comments,thank all of you.

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