FFR guided PCI for tandem lesions in prox-to-mid LAD

- Operator : Seung-Jung Park

FFR guided PCI for tandem lesions in prox-to-mid LAD
- Operator: Seung-Jung Park, MD
Clinical history

A 63 year-old female was presented with stable angina pectoris. Her coronary risk factors were hypertension, diabetes, and hyperlipidemia. Thallium SPECT showed reversible medium sized mild-to-moderately decreased perfusion in apical-mid anterior wall and treadmill test was positive at stage 4.

Baseline coronary angiogram

1. A right coronary angiogram showed mild atherosclerosis at mid RCA.(Figure 1)
2. A left coronary angiogram revealed a diffuse stenosis from the proximal LAD to mid LAD across two diagonal branches(Figure 2). LCX had mild to moderate stenosis in distal segment. (Figure 3)

Procedure

We focused on the LAD lesion which was corresponded to the result of thallium SPECT. Left coronary artery was engaged with an 8Fr JL 4 guiding catheter with side holes and LAD was crossed with a 0.014¡± BMW guidewire. We advanced a 0.014¡± pressure wire into the LAD along the previous giuidewire and removed the BMW guidewire. After adenosine infusion to get a maximum hyperemia, FFR value in distal LAD was 0.67. We couldn¡¯t pass an IVUS catheter distal to the very tight stenosis in the mid LAD. After predilatation with a 2.5 x 20 mm non-compliant balloon (Dura Star¢ç), we get an IVUS image showing two tight stenoses between 1st and 2nd diagonal branch with relatively normal segment just beyond the big septal branch.(Figure 4) A 2.75 x 28 mm Cypher stent was deployed in the mLAD with proximal stent landing on the normal segment just distal to the septal branch(Figure 5). After post dilatation using the 2.5 x 20 mm non-compliant balloon (Dura Star¢ç), we performed reexamination of FFR, and got a value of 0.90 within the segment between the septal branch and proximal part of stent and 0.90 distal to stent, respectively.(Figure 6) We decided not to stent the proximal lesion and finished procedure.( Movie 1)

Comments

  • Ayhan Olcay 2010-09-19 Dr Park, Those two FFR guided cases are very different from your previous cases and approach (very long stenting, 100% IVUS guidance, cosmetically perfect looking vessels, agressive postdilatation). Do you think this FFR guided cosmetically inferior approach will prevail over long stenting, 100% IVUS guidance ? How do you select your cases for FFR guided vs agressive stenting approach ? Thank you for your educative cases.
  • Seung-Jung Park 2010-09-25 Based on the published data (from AMC data), we have clear IVUS cut-off value of post stent CSA and stented length for good clinical outcomes (post stent CSA >5.5 mm2, and stented length <40mm). Actually, I believe good clinical outcome with another 18mm Cypher stent for particular this case. But still 2 procedural factors are important predictors of stent thrombosis and restenosis. 1. There was IVUS guided normal looking area between the two tandem lesions. 2. Still the shorter, the better. 3. Negative FFR (0.9) means abscence of ischemia. Negative FFR never lies. 4. IVUS MLA 2.7 mm2 doesn't mean anything. Recently, we made a new cut-off value of IVUS MLA (2.4 mm2, unpublished data) matched with FFR 0.80 and thallium scan too. 5. We just started prospective randomized study regarding FFR guided vs agressive stenting approach as you mentioned. Thank you for your advanced interest.

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