Antegrade Approach for Proximal LAD ISR CTO Lesion

- Operator : Seung-Whan Lee

Antegrade Approach for Proximal LAD ISR CTO Lesion
- Operator: Seung-Whan Lee, MD
Case Presentation
A 65 year-old gentleman was referred for CTO intervention. 10 years ago, he underwent PCI for narrowing of the LAD which ranged from ostium to mid portion with two Cypher stents. Since several months ago, he had suffered from exertional chest pain, which was confirmed to be caused by ischemic heart disease through functional studies. His coronary risk factors were smoking, hypertension, and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV function without RWMA. Exercise treadmill test showed ST depression on stage III with symptom. Thus, we performed coronary angiography.
Baseline Coronary Angiography
  1. The left coronary angiogram showed total occlusion of previous stents at mLAD ( Movie 1, Movie 2).
  2. The right coronary angiogram did not show any significant stenosis ( Movie 3).
Procedure
Right coronary artery , and left coronary artery were cannulated with a 7 Fr AL 1 diagnostic , and 7 r XB 3.5 SH guiding catheter through the bi-femoral approach, respectively. Initially, we tried antegrade approach through pLAD, using a 0.014 inch NEO¡¯s Fielder XT wire with FINECROSS 0.014 inch 1.8 Fr 130 cm microcatheter. After negotiation, we succeeded in engagement of a wire into dLAD with NEO¡¯s Fielder XT 0.014 inch - 190 cm wire, and predilatation was performed with Maverick 1.5 x 15 mm balloon at pLAD (Figure 1). After wiring the first diagonal branch with the NEO¡¯s Sion wire, additional predilatation was performed with Maverick 2.0 x 12 mm balloon (Figure 2). And then two drug-eluting balloons, SeQuent Please 2.5 * 30 mm, and 3.0 * 20 mm, were inflated in the mid, and distal LAD, respectively (Figure 3). Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).

Comments

  • Long Bui 2014-02-09 Congratulation successful case! But you can see a stent strut collapsing. What should we do?
  • Santoso Adhiwana 2014-02-09 Congrats. What is your objection not to use DES?
  • Seung-Whan Lee 2014-02-10 what is your objection not to use DES > thank you for your question. As you know, stent alredy covered mid-to distal LAD portion, so we didnot want to cover more distal with stent. Additional stent may be problem for the next option including MIDCAB. Congratulation successful case! But you can see a stent strut collapsing. What should we do? We dId IVUS after DEB, which showed that there was no stent collapse. thank you for your question

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