Distal LM Bifurcation Lesion with Procedure Related Thrombi

- Operator : Seung-Jung Park

Distal LM Bifurcation Lesion with Procedure Related Thrombi
- Operator: Seung-Jung Park, MD
Case Presentation
A 64-year-old woman presented with recently aggravated effort chest pain. Her coronary risk factor was hypertension. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=64%) without RWMA. Thallium SPECT showed reversible large sized perfusion defects in LAD and LCX territories.
Baseline Coronary Angiography
1. The left coronary angiogram showed severe stenosis at distal LM bifurcation and proximal to mid LAD ( Movie 1, Movie 2).
2. The right coronary artery was normal ( Movie 3).
Procedure
Five and Eight Fr sheaths were inserted into left and right femoral arteries, respectively. An 8 Fr JL 4 guiding catheter with side hole was engaged into left coronary artery ostium through right femoral artery. A 0.014 inch BMW wire was inserted into LAD. Initially, we checked IVUS at LM to mid LAD (LM-mLAD). Predilatation was performed at mid LAD with an Ikazuchi 2.0x20 mm balloon (Figure 1). After predilatation, following angiogram showed thrombi at mid LAD with TIMI grade I flow ( Movie 4). We injected abciximab into intracoronary and checked an activated clotting time (ACT). ACT value was 357 seconds. A Resolute intergrity stent 3.0x38mm at proximal to mid LAD was deployed (Figure 2, Movie 5). And then, we inserted a 0.014 inch BMW wire into LCX and deployed a Resolute Integrity stent 3.0 x 18 mm at LM to proximal LCX (Figure 3). Crushing was done with an Empira NC balloon 4.0x15mm at LM to pLAD (Figure 4). We deployed a Resolute integrity stent 4.0 x 26mm at LM to pLAD with overlapping (Figure 5). Additional balloon dilatation was done using Empira NC balloon 4.0x15mm at LM-pLAD. A 0.014 inch Fielder FC wire was inserted into LCX. Thereafter, additional balloon dilatations were done using Maverick 1.5x15mm and Ikazuchi 2.5x20mm at LM-pLCX, and an Empira NC 4.0x15mm at LM-pLAD. Final kissing balloon dilation was performed with an Empira NC 4.0x15mm at LM-pLAD and a Nimbus Salvo 3.0x17mm at LM-pLCX (Figure 6). Final angiogram showed well-expanded and well-positioned stents ( Movie 6).

Comments

  • Arash Gholoobi 2013-02-23 Seems like a dissection rather than thrombus in my eyes. What about diagonal? it's ostium looks to be significantly pinched.
  • Dr Joy Sanyal 2013-02-26 what is the reason for selection of fielder FC wire into Lcx.could it be achieved with any other hydrophilic wire.
  • Razmi Rahman 2013-03-29 after developing TIMI grad I flow in mid LAD for the management along with abciximab why did'n give the vasodilaters and calcium chenal blockers ?

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