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Left Main Bifurcation Treatment with Simple Cross-over stenting & Intermediate LAD lesion
- Operator : Seung-Whan Lee
Left Main Bifurcation Treatment with Simple Cross-over stenting & Intermediate LAD lesion |
- Operator: Seung-Whan Lee, MD |
Cilinical history |
A 56-year old gentleman was admitted to our hospital due to exertional angina for several months. His coronary risk factors were diabetes and hyperlipidemia. His physical examiniation was normal and cardic enzymes were normal. His ECG and chest X-ray were unremarkable. Echocardiography reveals no regional wall motion abnormality with normal LV systolic function. |
Coronary angiographic findings |
1) Rt. coronary angiography showed diffuse 30-50% stenosis from proximal to mid portion of right coronary artery (RCA). (Figure 1) |
Procedure |
A 7 Fr JL4 guiding catheter was engaged in left coronary artery through a right femoral approach. We crossed the 0.014 inch BMW wires into the LCX and LAD sequentially, and then performed intravascular ultrasound (IVUS) evaluation for LAD and LCx ostium. It showed the significant stenosis at the distal LMCA with cross sectional area (CSA) of 4.5mm2, however, LCx ostium appeared quiet normal, and proximal LAD had moderate eccentric atherosclerotic lesion. (Figure 4) Mid-LAD had mild to moderate eccentric plaque and negative remodeling with CSA 3.5 mm2. (Figure 5) In order to evaluate the hemodynamic impact of these lesions, we performed fractional flow reserve (FFR) in LAD. A 0.014¡± pressure wire was used for the FFR measurement, while hyperemia was induced by intravenous adenosine administration. FFR was 0.82 in the prox-LAD and 0.76 in the mid LAD. (Figure 6) We planned simple cross-over technique from LM to LAD across LCX. The proximal LAD to LMCA was dilated with Black Hawk 3.5/16 mm. Then, a 4.0/23 mm Xience V stent was placed at the proximal LAD to the LMCA at 12 atm. (Figure 7) A high pressure post-dilation was performed with a 4.5/12 mm Fortis balloon at 20 atm. (Figure 8) The final angiogram showed that the procedure was successful without compromising LCX ostium.(Figure 9, Figure 10) Then, we checked FFR for LAD again. FFR was 0.97 in the prox-LAD and 0.88 in the mid LAD. We finished the procedure. |
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