LM and LAD Bifurcation Lesions Treated by Double Crush Techniques

- Operator : Seung-Jung Park

LM and LAD Bifurcation Lesions Treated by Double Crush Techniques
- Operator: Seung-Jung Park, MD
Case Presentation
A 74 year-old gentleman was admitted for further evaluation of coronary artery disease. About one month ago, he had a medical check-up. At that time, his treadmill test was positive at recovery phase. His coronary risk factors were diabetes, hypertension, hyperlipidemia, and ex-smoker. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=59%) without RWMA. Thallium SPECT showed reversible large sized perfusion defects at LAD territory.
Baseline coronary angiography
1. The left coronary angiogram showed significant tight stenosis at LM and LAD bifurcation lesions. Another significant stenosis at proximal LCX was observed and distal LAD was totally occluded ( Movie 1, Movie 2, Movie 3).
2. The right coronary angiogram was near normal ( Movie 4).
Procedure
An 8 Fr JL 4 guiding catheter with side holes was engaged at the left coronary artery ostium through right femoral artery. And then, we inserted three 0.014 inch BMW wires into LAD, LCX and diagonal branch, respectively (Figure 1). Predilatation was performed at diagonal branch using a Maverick balloon 2.0x20mm (Figure 2). After predilatation, we sequentially deployed a Promus Element stent 2.5x20mm at diagonal branch (Figure 3) and a Promus Element stent 3.0x20mm at pmLAD (Figure 4). High pressure balloon dilatation was performed with a Dura Star NC balloon 3.0x10mm at pmLAD (Figure 5). Predilatation was performed with an Elect balloon 2.5x20mm at LM to pLCX (Figure 6). After predilatation, we tried to insert a Promus Element stent 3.0x38mm into LCX, but failed. So we inserted a stent into pLCX using a Heartrail catheter (Figure 7). Following balloon dilatation was performed with a Trek balloon 3.5x20mm at LM to pLAD (Figure 8). After that we deployed a Promus Element stent 3.5x24mm at LM to pLAD (Figure 9). Balloon dilatation was sequentially performed with a Dura Star NC balloon 3.0x10mm at pLCX (Figure 10) and with a Dura Star NC balloon 3.5x20mm at LM to pLAD (Figure 11). Following kissing ballooning was performed with a Dura Star NC balloon 3.5x20mm at LM to pLAD and with a Dura Star NC balloon 3.0x10mm at pLCX (Figure 12). Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).

Comments

  • Pei-Lung Hung 2012-05-18 Dear Prof. SJ Park, I have some questions about thos case. 1. Did the LAD-D2 and LAD-M need PCI? The inital flow is good. Maybe need FFR or IVUS data to decide PCI or not. 2. You inserted three GW initially. The PCI sequence was LAD-D2, LAD-M, LCX-P, and then LM to LAD-P. Why not used 2 GW in this case to decrease procedure complexity? 3. You used Promus Element stent 3.0x38mm in LCX-P to M. Is it a little bit oversizing? 3. The LAD-very D still have total occlusion.
  • Augusto Pichard 2012-05-20 agree with above The stents are way too long!! The trend now is to use "spot stenting with DES" covering the critical segment, and leaving the intermediate disease at the edges for "medical therapy". Only if the edge has >60% plaque burden, should one cover it with stent. A Pichard, Washington, DC
  • Won-Jang Kim 2012-05-21 Thank you for your valuable comments. Of course, we did a IVUS evaluation and diffuse large burden of plaues extended from mLAD to LM. There was no landing zone in pmLAD to do a spot stenting. After the IVUS evaluation, we initially decided LM stenting with crush technique that was why we used the 3 GW. As you can see, the small distal LAD lesion initially total occluded.

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