Intervention of proximal LAD lesion in patient with totally occluded LCX and RCA

- Operator : Seung-Jung Park

Intervention of proximal LAD lesion in patient with totally occluded LCX and RCA

- Operator: Seung-Jung Park, MD

Case Presentation

A 75 year-old man was referred to department of cardiology due to abnormal results of stress myocardial perfusion imaging. He had effort related chest pain and thallium scan showed partially reversible medium sized perfusion defect at LCX and RCA territory and the echocardiography showed akinesia of inferoposterolateral wall with moderate LV dysfunction (EF=45%). Coronary angiography showed severe triple vessel disease and we recommended CABG but he refused the operation with obstinacy. His coronary risk factors were hypertension and smoking.

Baseline coronary angiography

1. The left coronary angiogram showed eccentric 90% stenosis of proximal LAD bifurcation and total occlusion of proximal LCX and collaterals from LAD to LCX and RCA ( Movie 1, Movie 2, Movie 3, Movie 4). 2. The right coronary angiogram showed anomalous origin and total occlusion of mid RCA ( Movie 5).

Procedure

An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8Fr JL 4.0 catheter with side hole. A 0.014 inch Fielder FC wire was inserted into the LAD through the lesion and changed to a 0.014 inch Flexi-wire and then the Fielder FC wire was inserted the first diagonal branch. First, we checked the lesion with IVUS ( Movie 6). There was considerable plaque in the LM bifurcation on the IVUS, so we decided to cross-over the LCX. We pre-dilated the LAD using a ELECT 2.5 x 15 mm. Thereafter, we deployed a Resolute integrity stent 3.5 x 26mm at distal LM to proximal LAD ( Movie 7). Adjunctive post-stenting balloon dilatation was done using a Dura Star 3.5 x 15mm. Final left angiogram showed that the procedure was successful ( Movie 8, Movie 9, Movie 10). The patient remained stable state during periprocedural period.