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.
2) Lt. Coronary angiography showed tight stenosis in distal LM to proximal left circumflex artery (LCX) with relatively healthy left anterior descending artery (LAD) ostium( Movie 1, Movie 2).

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).

Comments

  • Jugessur Rabindranath 2010-08-17 Please send me the plugins for Firefox to be able to see the videos. Thank you
  • rehanomar siddiqi 2010-08-20 I dont have the plugins for Firefox to be able to see the videos. Help needed in this regard. Thanx.
  • Joao Alexandre Farjalla 2010-08-21 Great result, congrats! Follow up with coronary angiography?
  • Li Wah Tam 2010-08-21 It will be nice to look at the IVUS , good stratigies to use Rota for debulk, but it was a high risk procedure
  • M Tarek Mounir Zaki 2010-08-21 FIRST CONGRATULATIONS FOR A VERY NICE CASE.PLS SEND ME THE PLUGINS FOR FIREFOX .tHANX A LOT,
  • Dr. U.S.Ramjutun 2010-08-22 That was indeed a complex and challenging case.Bravo!Please give me the link to the Plugins to view the videos.Thanks a lot.
  • Marcelo Ribeiro 2010-08-22 Amazing job, congratulations! My questions are aiming at two points: first, what was the hindsight of not starting this case on top platelet inhibition? Second, have you considered to use a catheter like the Venturi to try facilitate wiring the LCX? Thank you!
  • Young-Hak Kim 2010-08-22 We are sorry for your inconvience to see the moving files. Please click the file and download the plugins. If it does not work, we will fix it. In terms of antiplatelet therapy, DAPT is our standard even for left main intervention. GPI is also given in such complex cases. Follow-up angiography is routinely recommended. But, from the view of clinical practice, it does not seem to be mandatory for all left main intervention. The Venturi may help. But, it is not available in Korea.
  • Stanley 2010-11-04 Nice job! How did you know that Rota debulking followed by Cutting balloon dilatation would not compromise the LCX flow ? To be honest, I had a feeling of insecurity of doing that before wiring succefully to the LCX.
  • Young-Hak Kim 2010-12-28 This procedure was done as a rescue to get in the LCX. Therefore, we do debulk the plaque, a complication of LCX occlusion is possible. However, if we put a lot of attention to prevent it, we can avoid the complication.

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