Case

Repeat Cypher implantation for a Cypher failure lesion at the left main coronary bifurcation

- Operator : Seung-Jung Park

Repeat Cypher implantation for a Cypher failure lesion at the left main coronary bifurcation
- Center : Live Case in Fu Wai Hospital, Beijing, China
- Operator: Seung-Jung Park, MD, Xuewen Qin, MD, Jinqing Yuan, MD
- IVUS Commentator: Gary Mintz, MD
History
A 55 year-old man was admitted for treatment of acute anterior myocardial infarction 6 month ago. His coronary risk factors were hyperlipidemia and family history of coronary artery disease. He underwent Cypher stents implantation at the proximal left anterior descending artery (LAD, 3.0 x 18 & 2.75 x 18 mm) and proximal left circumflex artery (LCX, 2.75 x 18 & 2.5 x 23 mm) (Figure 1: pre-treatment, Figure 2: post-treatment). Because of recurrent chest pain, he underwent a follow-up angiogram at 6 months. It showed a restenosis at the left main (LM) bifurcation with involvement of the ostial LAD and LCX, where was the proximal segment of the LCX stent and the proximal edge of the LAD stent (Figure 3, Figure 4). Echocardiography showed apical akinesia and normal LV ejection fraction (58%).
Procedure
An 8F sheath was inserted through the right femoral artery, and the left coronary ostium was engaged with an 8F JL 4 catheter. The LAD and LCX were wired with two 0.014 inch Choice PT wires. Intravascular ultrasound (IVUS) examination was performed from the LAD. It showed that a wire crossed a protruding strut of the LCX stent to the LAD (Figure 5-IVUS image, Figure 6-schematic illustration). Because the previously implanted LCX stent was extended to the distal LMCA crossing the ostial LAD, we planned to deploy a stent at the distal LM covering the ostial LAD stenosis after destructing a cell of the protruding LCX stent. Thus, we positioned a Maverick balloon (2.5 x 20mm) from LM to proximal LAD and inflated it to 12 atm (Figure 7, Figure 8). The following IVUS image showed that the piece of the LCX stent was successfully fractured. Then, a Cypher Select stent (3.0 x 18 mm, Cordis) was deployed at 12 atm (Figure 9, Figure 10, Figure 11). The final kissing balloon inflation was done with a Maverick balloon for LAD (2.5 x 20 mm) and another Maverick balloon for LCX (2.5 x 20 mm) (Figure 12). The final angiogram and IVUS showed a good result with optimal stent expansion (Figure 13, Figure 14).

Comments

  • xubo 2005-03-04 Yesterday, 6 months after the index procedure, the patient was contacted by our f-u group. He can do normal activity without any discomfort. Thanks, Dr.Park. Xu Bo, Fu Wai Hospital.
  • Zheng zhen guo 2005-03-05 LAD looks good before the first procedure, it was compromised after the first procedure - a worse procedure of the first PCI.
  • xubo 2005-03-06 The first procedure was performed at other hospital. Before our live demonstration last year, he was sent to Fu Wai Hospital because severe chest pain. Everybody can easily find a wrong position of LCX Cypher stent which was protruded into distal LM on the image after implantation immediately...The major teaching point that I can understand today should be the importance of IVUS guidance in such situation.
  • r.p.singh 2005-03-11 was it possible to reintoduce wireout side lcx stent under ivus guidance and deploy stent in lad and lm , crushing lcx stent

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