Slides
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) |
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. |
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