FFR-Guided Revascularization of a Tandem Lesion Involving mid LAD Bifurcation

- Operator : Seung-Jung Park

FFR-Guided Revascularization of a Tandem Lesion Involving mid LAD Bifurcation
- Operator: Seung-Jung Park, MD
Case Presentation
A 62 year-old gentle man came to the out-patient department with effort chest pain. His coronary risk factors were hypertension and past history of myocardial infarction. The physical examination and history indicated stable angina pectoris. Thallium SPECT showed a reversible large sized perfusion defect involving territories fed by the left anterior descending coronary artery (LAD). The patient was admitted, and coronary angiography was performed with the intention of percutaneous coronary intervention.
Baseline Coronary Angiogram
  1. A left coronary angiogram showed a tandem lesion involving mid LAD bifurcation ( Movie 1).
  2. There was no significant stenosis on a right coronary angiogram ( Movie 2).
Procedure
An 7 Fr sheath was inserted into the right femoral artery, and the left coronary ostium was engaged with an 7 Fr JL 4 catheter with side hole. First, 0.014-inch BMW wire was introduced into the LAD, and then the diagonal branch was wired with 0.014-inch Fielder FC wire for protection (Figure 1). On the basis of the IVUS finding, which showed the relatively spared diagonal ostium, the provisional stenting was planned for this lesion. Without predilation, 3.5 x 26mm Orsiro stent was implanted for the proximal one of the tandem lesion, which looked tighter than the distal one on angiography (Figure 2, Movie 3). For evaluation of the hemodynamic significance of the distal lesion, the pressure wire was introduced beyond it, FFR measuring 0.76. Based on the FFR value, another 3.0 x 22mm Orsiro stent was put into the distal lesion, overlapping the proximal stent (Figure 3, Movie 4). The Final angiogram showed near TIMI 3 flow through the diagonal branch, despite the angiographicaly compromised ostium of it ( Movie 5, Movie 6).

Comments

  • Sunip Banerjee 2015-03-23 I would have re-crossed the diagonal and do FKBI, verified finally with FFR, irrespective of final angiogram
  • ahn jung min 2015-03-27 Thank you for your suggestion. Side branch treatment after simple cross over stenting remains matter of debate. We did not perform FFR measurement and subsequent treatment due to following several reasons. First, only 1/3 of angiographic jailed side branches had functional significant stenosis in previous study. Second, in general, side branches did not supply myocardium large enough to affect patient clinical outcomes (e.g. ischemic burden>10%). Third, if side branch flow is TIMI 3, further kissing balloon or stenting may not improve clinical outcomes in previous studies, rather may be associated with worse main branch outcomes. Finally, patient was asymptomatic and there was no ischemic EKG changes. However, if you want to treat this lesion, FFR measurement prior to intervention would be good choice. We really appreciate your interest for our case.
  • Kunal Bikram Shaha 2016-07-29 I agree with Ahn Jung Min sir's comment as the diagonal is small and LAD's Final outcome shouldnot be compromised......A good illustration of provisional stenting I believe .Thankyou.

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