Occluded Left Main Bifurcation Lesion Treated by Primary Stenting in the Setting of Acute Myocardial Infarction

- Operator : Seung-Jung Park

Occluded Left Main Bifurcation Lesion Treated by Primary Stenting in the Setting of Acute Myocardial Infarction

- Operator: Young-Hak Kim, MD / Seung-Jung Park, MD, PhD
Case Presentation
The patient was 60 year-old male. He presented to the emergency room with persistent chest pain for 5 hours. He had a hypertension as a coronary risk factor. Baseline ECG showed ST elevation on precordial leads. Initial blood pressure was 70/30mmHg. He underwent emergent coronary angiography for primary PCI.
Baseline Coronary angiography
1. Left coronary angiogram showed subtotal LMCA bifurcation lesion with TIMI 2 flow (Figure 1).
2. RCA was normal with grade 1 intercoronary collateral to left coronary.
Procedure
An 8F sheath was inserted through both femoral artery and IABP was initially inserted through left femoral artery. The left coronary was engaged with an 8F Judkins catheter through right femoral sheath. Coronary angiogram showed subtotal occlusion in distal left main coronary artery (LMCA) including bifurcation with TIMI 2 flow. LAD and LCX were wired with two floppy guidewires. And then, distal LMCA to proximal LAD was dilated with a 3.0mm x 20mm balloon at 6 atm (Figure 2), after which the following angiography revealed no compromise of flow of LCX (Figure 3). Thus distal LMCA to proximal LAD was stented with a 3.5mm x 16mm Express stent at 9 atm crossing over LCX (Figure 4). Unfortunately, we found that LCX ostium became more narrowed after stenting. Because the LCX was not small artery, we decided further dilatation of LCX with or without stenting. LCX was reaccessed with floppy guidewire through the strut of stent and dilated with a 2.5mm x 20mm balloon at 6 atm (Figure 5). Then, Kissing balloon inflation was performed in LMCA-LAD with a 3.0mm x 20 mm balloon at 6 atm and in LMCA-LCX with a 2.5mm x 20mm balloon at 6atm (Figure 6). Final angiogram showed no residual narrowing at LCX and LAD ostium without additional stenting in LCX (Figure 7).

Comments

  • Yi-Heng Li 2004-01-26
  • jose luis 2006-09-11
  • SanjaySrivatsa 2006-09-21 The ostial restensois rate for the lcx in this location would be very high and given the size of the vessel a kissing balloon strategy followed by kissing stent reconstruction of the left main bifurcation would be more appealing long term than a stent and rescue ostium with PTCA strategy---of course time and expediency given a shocked patient may have necessitated a more pragmatic "stent the lm-lad and rescue the lcx approach" taken here. This is a young patient--- how will you follow him : would you do serial routine angiography +/- IVUS, CT angio, serial physiological perfusion imaging under stress,and if there is anatomic or physiologic compromise in future of your intervened site, will you refer to the CV surgeon or re-intervene-i would appreciate dr park and authors opinion? thanks sanjay srivatsa

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