LM Trifurcation Lesion with In-Stent Restenosis Treated by Crush Technique

- Operator : Seung-Jung Park

LM Trifurcation Lesion with In-Stent Restenosis Treated by Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 74 year-old male was referred to our hospital for a second opinion. 2 years ago, he underwent percutaneous coronary intervention (PCI) at proximal LAD because of unstable angina. 6 months ago, the follow-up coronary angiogram showed severe stenosis at distal left main (LM) coronary artery with concomitant involvement of proximal LAD, LCX and ramus intermedius. His coronary risk factors were hypertension and hyperlipidemia. His baseline ECG and cardiac markers were unremarkable.
Baseline Coronary Angiography
  1. The left coronary angiogram showed severe stenosis at LM trifurcation with instent-restenosis at proximal edge of proximal LAD stent.( Movie 1, Movie 2)
  2. The right coronary angiogram showed diminutive RCA.(Figure 1)
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8F JL catheter with 4.0 cm curve. The 0.014-inch 190cm Balanced Middleweight (BMW) wire was inserted into the LAD and another BMW wire was inserted in to the LCX. LM to proximal LAD was pre-dilated with 3.0 X 15mm non-compliant (NC) TREK balloon.(Figure 2) And we also pre-dilated LM to proximal LCX using the same balloon.(Figure 3) Thereafter a Xience Alpine 4.0 X 18 mm stent was successfully deployed at LM to proximal LCX.(Figure 4). And then kissing ballooning was performed by using a NC TREK 3.5 X 15mm at LM to proximal LCX and a SeQuent Please 3.5 x 17mm at LM to proximal LAD.(Figure 5). Final left angiogram and IVUS showed that the procedure was successful.( Movie 3, Movie 4)

Comments

  • hamid sharif khan 2016-05-03 You have not mentioned deployment of LAD stent in the text
  • Se Hun Kang 2016-05-03 Two years ago, pLAD was treated with PCI at other hospital. Stent was implanted from dLM to pLCX, pLAD was treated with DEB during current procedure.
  • Kunal Bikram Shaha 2016-07-23 Don't you agree that because of ballooning in proximal lad there is a hazy zone indicating edge dissection..What is your opinion of culloting the stent with additional stent from left main to cover the proximal instent restenotic segment - would have been better-just a thought.
  • Se Hun Kang 2016-07-25 Thank you for your comment. It might be looked as edge dissection, but IVUS image showed no definite edge dissections. About two stent technique, it might be possible with another stent in LAD to left main and with culotte technique, but there was no significant differences between the two stent techniques. There was small protrusion of LAD stent to left main on IVUS image, so we choose more simple procedure with Crush technique with only one more stent.

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