FFR guided PCI in multivessel disease including mid LAD Bare-Metal Stent in-stent restenosis

- Operator : Seung-Jung Park

FFR guided PCI in multivessel disease including mid LAD Bare-Metal Stent in-stent restenosis
- Operator: Seung-Jung Park, MD
Clinical history

A 63-year-old man was admitted for aggravated angina for 2 months. About 10 years ago, he received two bare-metal stents (BMS) implantation at proximal-to-mid LAD. His cardiovascular risk factors were hypertension and hyperlipidemia.

Coronary angiographic findings

1) Rt. coronary angiography showed diffuse 60-70% stenosis at mid segment of right coronary artery (RCA) with collateral flow to obtuse marginal branch of LCX. ( Movie 1)
2) Lt. coronary angiography showed significantly focal stenotic lesion of in-stent of mid LAD total occlusion of obtuse marginal branch and tubular 80% stenosis in the distal left circumflex(LCX) proper (LCX). ( Movie 2, Movie 3)

Procedure

An 8 Fr sheath was inserted into right femoral artery, and the left coronary artery was engaged with a 8 Fr JL4 guiding catheter. A 0.014¡± BMW wire was positioned in the LAD and another intermediate 0.014¡±soft wire was inserted into the diagonal branch (Figure 1). IVUS study showed significant neointimal hyperplasia with calcification in the ISR lesion of mid-LAD (Figure 2). Firstly, we performed balloon angioplasty with 3.5x10mm cutting balloon. Because the lesion was focal and flow was good, we did not perform additional stenting (Figure 3, Figure 4). The OM branch was totally occluded with collateral flow from RCA. The OM supplying myocardial territory was not so big, so we decided to leave it alone. And then, in order to evaluate the hemodynamic impact of the remained distal LCX proper and RCA lesions, we performed fractional flow reserve (FFR) measurement and IVSU examination, simultaneously. IVUS examination showed eccentric calcification with relatively small vessel diameter (reference vessel diameter 2.4 mm) and minimal luminal area (MLA) was 1.9 mm2. A 0.014¡± pressure wire was used for the FFR measurement, while hyperemia was induced by intravenous adenosine administration. FFR was 0.94 in the distal LCX lesion (Figure 5, Figure 6, Figure 7). The RCA was engaged with a 7 Fr JR4 guiding catheter and we performed FFR for the RCA lesion at the same manner. FFR was 0.85. (Figure 8, Figure 9) IVUS revealed MLA was 2.6mm2 at the tightest lesion in the RCA. Based on the above results, we decided to finish this procedure. And then after, we checked thallium spect and treadmill test for validation of clinical and residual ischemic status. Thallium spect showed small territory, partially reversible perfusion defect in obtuse marginal territory (Figure 10), but the treadmill test showed normal exercise capacity up to stage IV achieving target heart without any ST-T segment change (Figure 11). The patient feels free of angina.

Comments

  • Nicolaus J. Reifart 2010-09-24 Unfortunately I was unable to download the movies. Collateral flow allways means that the lesion is hemodynamically very severe. If the RCA supplied the CX then 1. the CX lesion was severe irrespective from what you found with FFR and 2. the RCA lesion has prognostic importance and does not fall into the category of DEFER lesions. 0.85 means that this might be sufficient for the RCA territory, but not for both. You should have stented it or opened the CX.
  • Seung-Jung Park 2010-09-27 How are you ! We will help you regarding technical problem soon. 1. the LCX lesion was involed distal bifurcation. OM branch was totally occluded which was supplied by RCA collaterals. Remaining distal LCX proper disease has 80% narrowing, and FFR was 0.94 which may be related with small myocardium or physiologically insiginificant. 2. the RCA was big, which gave collateral into totally occluded the LCX OM branch too. I fully agree that the RCA is really important for patient's prognosis. However, I think FFR 0.85 (at adequate maximal hyperemia) may include the collateral supply too. After defer, we got non-invasive stress test including treadmill test and thallium scam again in almost all cases in order to get data. In particular this patient, we have negative treatmill test at stage 5 Bruce protocol and small reversible perfusion defect only in occluded OM branch (these results of noninvasive stress tests will be presented in this web site soon). This is really big mismatch among angiographic severity, FFR and noninvasive stress test. I would like to believe FFR 0.85 matched excellent patient's exercise performance and small sized perfusion defect of the LCX OM. This clinical decision -treat on not treat - mainly relied on noninvasive stress test. Recently, we just started the study about the natural prognosis of patients who have a normal myocardial perfusion scan (and/or normal TMT) with angiographically proven significant disease (>50%, mainly deferred patients group: IRIS-FFR registry study, >3000 patients will be included). I still am on your side, however I would like to believe negative noninvasive stress test (matched FFR 0.85) in terms of longterm clinical outcomes whatever angiographic finding is. Thank you for your comments and advanced interest.

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