Treatment of LM ostial in-stent restenosis lesion

- Operator : Seung-Jung Park

Treatment of LM ostial in-stent restenosis lesion
- Operator: Seung-Jung Park, MD
Clinical History

A 52-year old woman was admitted for minimal effort chest pain for 1 month. 1 year ago, she had got PCI at LM ostium with Xience (4.0*15mm). Her cardiovascular risk factors were hypertension and diabetes. In her echocardiographic exam, LVEF was preserved without regional wall motion abnormality.

Coronary angiographic findings

Right coronary angiogram showed normal RCA with collateral flow to LAD.( Movie 1)
Left coronary angiogram showed total occlusion of In-stent LMCA ostium.( Movie 2).

Procedure

A 8 Fr sheath was inserted into the right femoral artery and 5 Fr sheath was also inserted into left femoral artery for preparation of IABP use. Left coronary ostium was engaged with a 8 Fr JL 3.5 guiding catheter. A 0.014 inch BMW wire couldn¡¯t be inserted LMCA ISR lesion. After changing wire to 0.014 inch Choice PT with FINECROSS(micro-guide catheter), wiring could be performed into LAD and LCx. (Figure 1) On IVUS exam, large plaque burden with soft atheroma was showed in the LM ISR lesion.( Movie 3) We pre-dilated with Sprinter 2.5*15mm at LMCA ISR lesion ( Movie 4) and we dilated with cutting balloon 3.5*10mm 4 times. After cutting ballooning, we used non-compliant balloon, Nimbus Salvo 4.0*13mm and also used the drug coating balloon, SeQuent Please 4.0*17mm up to 7atm for 60 seconds. ( Movie 5) We performed Kissing stenting with Xience stents (dLM-LAD: 3.0*23mm /dLM-LCx: 3.0*28mm). After Kissing stenting, we performed kissing balloon with Durastar 3.0*15mm at LM-pLAD and stent balloon at LCx. Final IVUS and coronary angiogram showed successful PCI at LMCA and bifurcation lesion. ( Movie 6, Movie 7)

Comments

  • Emanoel Oepangat 2010-11-19 Dear Dr. Park, It is really an interesting and challenging case. I just would like your insight on one thing though..; from my experience in LM intervention, and also during my training, I have never inflate a ballon on the left main for more than 30 seconds. Even for less than that, I've had a problem with the patient developing a severe angina, a significant change in the ECG and also a dropped in the BP. In this case, using the SeQuent Please DEB, you have inflated for about 60 seconds. Are there any clinical changes on the patients, and what did you do to solve that? or because of the collateral from the RCA, it's kind a like a protected LM and the patient has no problem whatsoever? is that the usual procedure in your Cathlab, in regards to the time of ballon inflation for the LM? And in your vast experience, what is the optimal inflation time to get a good apposition of stent for the LM, albeit that we don't have the luxury of having IVUS in the cathlab? Thank you very much. Emanoel Oepangat, MD Jakarta-Indonesia
  • Young-Hak Kim 2010-11-19 We got the drug balloon inflated for at least more than 30 seconds to provide enough drug diffusion. Of course, during the procedure, we carefully monitored blood pressure and patient's symptom. In our previous experience of balloon-filled radiation for left main ISR, we had never experiened any serious problem related with long-duration balloon inflation because careful monitoring was performed. In unstable hemodynamic condition, repeated balloon inflation can be done while the balloon is place in the left main.
  • Li Wah Tam 2010-11-20 dear dr park , Great case, just want to ask : will there be any problem of implanated a drug eluting stent after DEB dilatation ? any risk of drug toxoxity resulting in late stent thrombosis or coronary aneurysm. thank you. . Li Wah Tam , HK
  • Young-Hak Kim 2010-11-20 We do not have data about the cumulated toxicity of drug. However, considering the rapid release kinetics of drug balloon and the period of implanted stent, the problem may not be significant.
  • Vijay Shah 2011-03-05 Great idea!Of drug eluting ballon coated with paclitaxel followed by everolimus coated Xience DES.....so that there is no overdose of single drug at the same site.This should ensure preventing re-restenosis....dr v t shah...mumbai (India)

Leave a comment

Sign in to leave a comment.