Two bifurcation lesions, treated with different technique

- Operator : Seung-Jung Park

Two bifurcation lesions, treated with different technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 71 year old man was admitted with unstable angina pectoris. 5-years ago, he had got stenting at right coronary artery and he was on the regular medication. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=65%) without regional wall motion abnormality.
Baseline Coronary Angiography
The left coronary angiogram showed very tight stenosis at distal left main (LM) bifurcation lesion. Also, at the mid-LAD bifurcation, there was tight stenosis. ( Movie 1, Movie 2)
The right coronary angiogram showed patent previous stent with mild diffuse stenosis.
Procedure
An 8 Fr EBU 3.5 guiding catheter was engaged into the left main ostium. Three 0.014 inch Floppy wires were introduced into the LAD, LCX, and 1st Diagonal (D1). ( Movie 3) And then we did IVUS examination; IVUS findings in Diagonal branch showed large plaque burden and very tight stenosis at ostium( Movie 4), however, IVUS finding in circumflex artery showed quite big vessel size and relatively big lumen area( Movie 5). Based on the IVUS findings, we decided treatment strategy for treatment of two bifurcation lesion. We performed balloon dilatation at the distal LM to the proximal LAD with Sprinter 2.5 x 15mm. Using with a Sprinter 2.5 x 15mm, predilation was performed for diagonal branch. ( Movie 6) And we deployed a Promus Element Stent 2.75 x 20mm across bifurcation site of D1. ( Movie 7) The balloon (Dura Star 3.0 x 15mm) in the mid- LAD was expanded after removing the wire at D1. ( Movie 8) After re-wiring of 0.014 inch Floppy wire at D2, the balloon dilation with Sprinter 2.5 X 15mm was performed at the mid-LAD and then a Promus Element Stent 3.0 x 28mm was expanded in the LAD. ( Movie 9) For the final kissing balloon dilation, the D1 was rewired with 0.014 inch Floppy wire; and balloon dilation was performed using with an Ikazuchi 1.5 x 15mm. Then, final kissing balloon dilation was performed with a Voyager NC 3.0 x 15mm in the LAD and an Ikazuchi 2.5 x 15mm in D1. ( Movie 10) We planned cross-over technique from LM to LAD across LCX. Then, a Promus Element stent 4.0/28 mm was placed at the proximal LAD to the LMCA at 10 atm. ( Movie 11) After re-wiring with 0.014 inch Floppy wire at the LCX, the kissing balloon dilation was performed with a Stent balloon 4.0 x 28mm in the LM and a Sprinter 2.5 x 15mm in the LCX. ( Movie 12) Final angiogram showed well-expanded and well-positioned stents. ( Movie 13, Movie 14)

Comments

  • Hisham 2011-02-25 Excellent work for this tough and difficult case. Really I liked it
  • Seung-Jung Park 2011-02-25 Thank you for your kind words.
  • Ben He 2011-03-04 good job
  • Zhonghan Ni 2011-03-05 1.do you agree that this procedure can be finished with 7Fr Guiding?why did you choose a 8Fr one? 2.the LCX ostium was not satisfactory to some extent,which might result from the LM-LAD struts,whether another run of IVUS was done? 3.your reply is very expected! Thanks.
  • Young-Hak Kim 2011-03-05 This procedure can be done with 7Fr guiding. However, to facilitate complex bifurcation treatment, Dr. Park picked up 8Fr guiding. In fact, a closure device can seal 8 Fr hole effectively. IVUS un from LAD and LCX showed good patency in both branches, so that further treatment was not done for ostial LCX.
  • Li Wah Tam 2011-03-05 Nice Job. Any special reason to use a 2.75mm stent at D1 , then use a 2.5mm balloon for post-dilatation & final kissing ?
  • Young-Hak Kim 2011-03-05 Thanks for your question. Due to a difficulty to advance a non-compliant balloon to the D1 branch, 2.5mm compliant balloon was used in finall kissing balloon inflation. In general, Dr. Park is using non-compliant balloons in the same size to the stent used in final kissing balloon inflation.
  • C. R. Kiamco 2011-03-08 Very nice work! can you put the final pullback from the LCx-LM? this can help to understand the image in the ostium.
  • Bhupesh Shah 2011-03-08 very good case would you likt to do check angiogram for lcx in future and if you find some restenosis then you would go for provisional lcx stent in future
  • Young-Hak Kim 2011-03-08 Dr. Park examed both branches with IVUS. Final IVUS showed good patency of ostial LCX. Angiographic hazziness was related with combination of carina shift, stent strut and mild plaque burden without significant lumen narrowing.
  • Abdulrahman Almoghairi 2011-03-11 good job but why you did not stent ostial LCX
  • Jingjin Che 2011-03-12 such nice a job. but how about do you think to treat LM bifurcation firstly?
  • Young-Hak Kim 2011-03-12 In general, the distal lesion is treated first to avoid difficulty in advancing stent or balloon into the distal part when the proximal lesion is stented. But, if the left main stenosis is very significant and provoking hemodynamic instability even after balloon inflation, we have to treat the left main first.

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