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Left Main Coronary Artery Bifurcation Stenosis with Normal LCX, Treated with DCA and Stenting

- Operator : Seung-Jung Park

Left Main Coronary Artery Bifurcation Stenosis with Normal LCX, Treated with DCA and Stenting

- Operator : Seung-Jung Park, MD
Case presentation
The patient was 51 year-old male admitted with stable angina for 3 month. His coronary risk factor was 30 pack-year of smoking. His baseline ECG showed T inversion in V1-V3. Echocardiography showed good left ventricular function with an ejection fraction of 60%.
Baseline coronary angiography
1. Left coronary angiogram showed distal left main coronary artery (LMCA) bifurcation lesion with the involvement of ostium of left anterior descending artery (LAD) (Figure 1). Ostium of left circumflex artery (LCX) was shown to be normal. Proximal reference vessel diameter was measured 4.8mm with a lesion minimal lumen diameter (MLD) of 1.6mm and a lesion length of 8.9mm (%diameter stenosis=66 %) by QCA analysis. The MLD of distal reference vessel (LAD) was 3.8mm.

2. Right coronary artery was normal.
Intravascular ultrasound
Left main to LAD was wired with 0.014 Fr directional coronary atherectomy (DCA) wire. IVUS was performed through the wire. IVUS image showed the tight stenosis at LMCA bifurcation (Figure 2). IVUS image revealed patent LCX ostium. EEM CSA (external elastic membrane cross sectional area) of LMCA bifurcation was 12.9mm2 and lumen CSA was 1.6mm2. EEM CSA of Proximal reference was 14.6mm2 and lumen CSA was 9.4mm2 (Figure 3).
Planned strategy
Stenting after DCA in distal LMCA crossing over ostium of LCX was planned.
Procedure
A 10F sheath was inserted through right femoral artery and the left coronary was engaged with a 10F Judkins left catheter. Left main to LAD was wired with 0.014" DCA wire. The 7Fr DCA device (3.5-4.0mm) was advanced into the distal LMCA and LAD ostium. And then 9 cuts were made (Figure 4). Angiogram (Figure 5) and IVUS image following DCA showed significant plaque reduction (Figure 6) in LMCA bifurcation. Plaque burden was decreased from 88% to 44%. Without post-DCA balloon dilatation, distal LMCA and LAD ostium was stented with a 4.0 mm x 9 mm NIR stent at 16 atm crossing over LCX ostium (Figure 7). Following angiogram showed narrowed LCX ostium (Figure 8). Thus Choice PT wire was placed into LCX. Then, LCX ostium was dilated with a 4.5mm x 9mm balloon at 14 atm and followed by kissing balloon dilatation with a 3.5mm x 13 mm balloon at 12 atm in LMCA-LAD and a 4.5mm x 9mm balloon at 14 atm in LMCA-LCX, simultaneously (Figure 9). Final angiogram showed a good result with LMCA MLD of 4.8mm and LCX MLD of 3.2mm (Figure 10). By IVUS image after procedure, lesion EEM was 21.9 mm2 and final stent area was 15.5 mm2 (Figure 11).

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