Slides

Left Main CTO Coronary Intervention with Crush Technique

- Operator : Seung-Jung Park

Left Main CTO Coronary Intervention with Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 51 year-old man was admitted with stable angina pectoris. His coronary risk factor was dyslipidemia and the physical examination was otherwise normal. The ECG and cardiac enzymes were unremarkable but treadmill test was positive on stage 2. The echocardiography showed normal left ventricular function (EF=65%) without regional wall motion abnormality.
Baseline Coronary Angiography
The left coronary angiogram showed total occlusion of left main ( Movie 1). And the right coronary angiogram revealed collateral grade 3 to LAD and LCx ( Movie 2).
Procedure
A 8Fr XB 3.5 SH guiding catheter was engaged in the left coronary artery through the right femoral artery. And a 5Fr Judkins right diagnosic catheter was engaged in the right coronary artery through the left femoral artery ( Movie 3). A 0.014-inch Fielder XT wire with finecross micro-guide catheter was inserted into the LAD and then the wire was exchanged for 0.014-inch BMW wire (Figure 1). We predilated at LM to osLAD using Tazuna 1.5 X 15mm balloon and then wired LCx with 0.014-inch BMW wire (Figure 2). LM to osLAD was predilated with Tazuna 2.5 X 15 mm and osLCx was predilated with Tazuna 1.5 X 15 mm several times ( Movie 4). Firstly, Resolute Integrity stent 2.75 X 12 mm was deployed at osLCx and then, Resolute Integrity 3.5 X 26 mm was deployed at LM to proximal LAD by Crushing technique (Figure 3, Figure 4). And then, we performed kissing balloon using Empira NC 2.75 X 15 mm at osLCx and Pantera LEO 3.5 X 15 mm at dLM to pLAD (Movie 4). After IVUS examination, adjunctive post-stenting balloon dilatation using the same balloon at bifurcation site. Final left angiogram and IVUS showed that the procedure was successful ( Movie 5).

Comments

  • Bing Liu 2014-06-20 Excellent! Is the single-stent strategy(cross-over) acceptable?
  • le van tu 2014-07-08 Excellent, Congratulation ! but, do you think CABG surgery better than intervention in this case ?
  • Long Bui 2014-07-19 I thịnk the best choice is doing nothing this case, because patient had good collateral from RCA to LAD and LCX. The examination also reveals stable angina and normal cardiac funtion. Optimal medication therapy is my option.
  • ahn jung min 2014-07-21 Thank you for your valuable comments. To Long Bui, COURAGE trial demonstrated that optimal medical treatment and PCI showed the comparable clinical prognosis regarding the risk of death or MI. However, left main disease (DS>50%) was excluded in the study population. Therefore, currently, this may be the area of uncertainty and further studies were necessary. However, we thought PCI would be more effective at least in angina relief considering the large ischemic burden, so we chose the revascularization. To le van tu, I agree with your opinion. But we thought PCI could be done safely due to 1) short total segment; 2)visible antegrade flow; 3)physiologically protected left main disease; 4)no significant distal disease. To Bing Liu, in general, the single cross over stenting was preferred. But in this case, IVUS evaluation revealed significant LCX ostial stenosis. So, we chose the crushing technique. I really appreciated your interest again.
  • Long Bui 2014-07-23 Thanks for clear explanation from Ahn jung min. I agree with you, the advantage of PCI in this case is to relieve angina and to improve QOL. I will chose the Crush technique also.

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