Slides
Treatment of complex left main bifurcation lesion
- Operator : Seung-Jung Park
Treatment of complex left main bifurcation lesion |
- Operator: Seung-Jung Park, MD |
Cilinical history |
A 77- year old man was admitted with effort chest pain (CCS class III) which was getting worse during last 1 week. His risk factor was hypertension. Echocardiography showed good left ventricular function with an ejection fraction of 68%. |
Coronary angiographic findings |
1) Rt. Coronary angiography showed diffuse 20-30% stenosis at mRCA. |
Procedure |
The left coronary artery was engaged with a 8Fr JL4 guiding catheter with side hall, and 0.014 inch BMW guide-wire inserted into LAD. We tried to insert guide-wire into LCX with Neo¡¯s soft wire and Choice PT wire. During wiring, the flow of LCX was getting worse and patient complained severe chest pain with ST segment elevation in ECG (Figure 1, Figure 2). Therefore, we inserted IABP and started to infuse Glycoprotein IIb/IIIa inhibitor. We tried to wiring into LCX with Shinobi wire and micro-guide catheter (Finecross 0.014¡¯, 1.8Fr, 130cm), but it didn¡¯t work. To evaluate LCX ostium, we did IVUS exam from pLAD to dLM. IVUS showed very tight stenosis superficial calcification at dLM, especially just proximal part of LCX os. Judging from IVUS exam, wiring into LCX would not be easy. After IVUS exam, it was showed that LAD flow was decreased. We decided to use of Rota ablation and cutting balloon at dLM.( Movie 3). After Rota ablation and cutting balloon (3.5*10mm, upto14atm), LAD & LCX flow was getting better and Finecross with Shinobi wire could be passed into LCx. We changed Shinobi wire to BMW and predilated with Maverick 2.5*20mm balloon upto 12 atm at pLCX(Figure 3, Figure 4). To evaluate vessel size and lesion length, we did IVUS exam at LM-LAD, LM-LCX. A Xience V stent (2.75*18mm) was deployed at pLCX and we did post-dilatation with high-pressure balloon with Dura-star 3.5*20mm upto 16 atm. And then, we predilated LM-pLAD with Dura-star (3.5*20mm upto20atm) and deployed Xience V 3.5*23mm. We did post dilatation with Dura-star 3.5*20mm upto 20 atm at LM-pLAD and did Kissing balloon with Quantum 2.75*20mm at pLCX, with Dura-star 3.5*20 at LM-pLAD upto10atm (Figure 5). Final angiogram showed successful stenting at LM bifurcation lesion with crush technique( Movie 4, Movie 5). |
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