Angiographically intermediate LM bifurcation lesion with significant FFR

- Operator : Seung-Jung Park

Angiographically intermediate LM bifurcation lesion with significant FFR
- Operator: Seung-Jung Park, MD
Cilinical history

A 42-year-old gentleman was admitted with exertional angina for 2 months. His coronary risk factors were hypertension, hyperlipidemia and smoking. Thallium SPECT showed normal gated myocardial perfusion with normal LV systolic function. Treadmill test revealed positive result at stage 3.

Coronary angiographic findings

1) RCA: mild, not obstructed (Figure 1)
2) distal LM to LAD: intermediate, diffuse disease ( Movie 1)
3) LCX: intermediate disease ( Movie 2)

Procedure

In order to evaluate the hemodynamic impct of these lesions, we performed fractional flow reserve (FFR) measurement in both vessels. A 8 Fr JL 4 guiding catheter was used for the LAD. A 0.014¡± pressure wire was used for the FFR measurement, while hyperemia was induced by intravenous adenosine administration. FFR was 0.74 in the mid-LAD and 0.72 in the LCX. Also, we performed grayscale intravascular ultrasound(IVUS) and virtual histology (VH) - IVUS examinations in both vessels. From LM to LAD, It was revealed ruptured plaque, thrombi and a substantial amount of necrotic core (Figure 2, Figure 3). In the LCX, significant stenosis and abundant plaque burden were showed (Figure 4, Figure 5). Based on the above results we decided to perform angioplasty of the distal LM, LAD and LCX. A 0.014¡± BMW guidewire was positioned in the LAD and another 0.014¡± BMW wire was positioned in the LCX. We predilated with 3.0 X 20mm Black Hawk balloon at pLAD in the first (Figure 6). And then, 3.0 X 24 PROMUS Element stent was directly implanted at pLCX and 3.5 X 28 PROMUS Element stent was implanted at LM to pLAD with crushing technique(Figure 7, Figure 8). After final kissing balloon was done, the procedure was finished (Figure 9, Figure 10, Figure 11).

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