Side-branch protection with multiple wiring in diffuse long lesion

- Operator : Seung-Jung Park

Side-branch protection with multiple wiring in diffuse long lesion
- Operator: Seung-Jung Park, MD
Clinical History

A 75-year old man was visited out-patient clinic for recent effort chest pain. After routine evaluation, He was admitted due to Treadmill test result (Stage 2, Positive). His cardiovascular risk factors were history of stroke 15 years ago and dyslipidemia. In his echocardiographic exam, LVEF was preserved without regional wall motion abnormality.

Coronary angiographic findings

Right coronary angiogram showed 30-40% stenosis at pRCA and 60-70% diffuse stenosis at dRCA.(FFR value of dRCA was 0.81) ( Movie 1) Left coronary angiogram showed sub-total occlusion at pLAD and diffuse stenosis at mLAD(FFR value at mLAD was 0.67) with multiple significant stenosis at diagonal branches ( Movie 2, Movie 3).

Procedure

A 7 Fr sheath was inserted into the right radial artery and left coronary ostium was engaged with a 7 Fr JL 4.0 guiding catheter. A 0.014 inch BMW wire was inserted to LAD. For protecting multiple diseased diagonal branches, we inserted 0.014 inch NEO¡¯s soft wire into 4th diagonal branch, 0.014 inch Runthrough NS wire into 1st diagonal branch and 0.014 inch Choice PT wire into 2nd diagonal branch ( Movie 4). And then, pre-dilatation was done with Maverick 2.5*15mm and two Xience stents (2.75*28mm, 3.5*38mm) were overlapped at dLAD to dLM ( Movie 5, Movie 6). After stenting, IVUS exam was done and we did high pressure balloon with Quantum 3.5*15mm at mdLAD, 4.0*15mm at pLAD to dLM. Final IVUS and angiogram showed successful PCI at dLAD to dLM with protection of diseased diagonal branches ( Movie 7).

Comments

  • Guanghui Chen 2010-11-24 I wish the operator to tell if the interwine of three wires set obstacle to the delivery of balloon or stent? if it does occur, what would you do?
  • Won-Jang Kim 2010-11-25 If the side branch has no disease, the wire protection usually is not recommended. In the diseased side branch cases, if those have the short segment and acute angle with main branch, most of them have no problem. Ostial discrete lesions are usually related with negative remodeling, and then they have low plaque burden. However, if those have the diffuse and wide angle with main branch, it has more chances to compromise after main stenting. In this case, it had the diseased side branches, and we tried to protect, although the third one was technically impossible. Fortunately, final results of this case were good.
  • Young-Hak Kim 2010-11-25 We have never experienced any serious probem related with the protected (jailed) wire. However, please remember not to use the used wires for the side branch. The wires damaged can be stuck between the stent and vessel wall.

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