Case

Unprotected Left Main Stenting with Debulking for Focal Shaft Stenosis : IVUS guidance

- Operator : Seong-Wook Park

Unprotected Left Main Stenting with Debulking for Focal Shaft Stenosis
: IVUS guidance
- Operator : Seong-Wook Park, MD
Case presentation
The patient was a 50 year-old man with effort angina for 3 months. His coronary risk factors included 30 pack years of smoking and hypertension. His baseline ECG showed normal. Left ventricular ejection fraction was 63% without regional wall motion abnormalities.
Baseline coronary angiography
1. Baseline coronary angiogram showed LMCA shaft narrowing (Figure 1). By QCA analysis, reference vessel diameter was measured 3.9mm with a lesion MLD (minimal lumen diameter) of 1.2 mm (% diameter stenosis=69%) and a lesion length of 11.3 mm.

2. LCX and RCA were normal.
Intravascular ultrasound
Left main to LAD was wired with 0.014 Fr Flexicut wire. IVUS was performed through the wire. IVUS image showed tight stenosis at LMCA shaft (Figure 2). Lesion EEM CSA (external elastic membrane cross sectional area) was 11.3mm2 and lumen CSA was 1.8mm2. Distal reference EEM CSA was 13.9mm2 and lumen CSA was 8.5 mm2 (Figure 3).
Procedure
An 8F sheath was inserted through right femoral artery and the left coronary was engaged with an 8F XB catheter. Left main to LAD was wired with 0.014Fr Flexicut wire. The 7Fr Flexicut directional coronary atherectomy (DCA) device (3.5-4.0mm) was advanced into the LMCA lesion, and 6 cuts were made. Following angiogram after DCA is shown in Figure 4. Then, IVUS image following DCA showed significant plaque reduction (Figure 5). Plaque burden was decreased from 84 % to 36%. Without post-DCA balloon dilatation, the LMCA was stented with a 4.0mm ве 14mm Arthos stent with 12 atm (Figure 6). Final angiogram showed a good result with QCA measurement of LMCA MLD of 3.8mm (Figure 7). By IVUS image after procedure, lesion EEM was 18.6mm2 and final stent area was 13.1 mm2 (Figure 8).

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