Case

Left Main Coronary Artery Total Occlusion Intervention in a Patient with Right Coronary Artery Ostial Lesion Complicated by Subacute Stent Thrombosis

- Operator : Seung-Woon Rha

Left Main Coronary Artery Total Occlusion Intervention in a Patient with Right Coronary Artery Ostial Lesion Complicated by Subacute Stent Thrombosis
- Operator : Seung-Woon Rha, MD
Clinical presentation
A 48 year-old woman visited our emergency room with typical sustained substernal chest pain for an hour. She had a history of hypertension and cerebral infarction. She suffered from effort chest pain with squeezing nature since 6 months ago. Initial ECG showed abnormal Q-waves in V1-3 and downslope ST depression in V 4-6 with marked elevation of CK-MB (69.8 ng/ml). Urgent 2D Echocardiography showed akinetic whole anterior wall and ejection fraction was 40%.
Baseline coronary angiogram

CAG demonstrated total occlusion at the mid of left main (LM) coronary artery and moderate to severe stenosis in right coronary arery (RCA) ostium. Diffuse collaterals were visualized from RCA to proximal left anterior descending artery (LAD). (Figure 1, Figure 2, Figure 3)

Procedure

Using a 7F JL4 guiding catheter and BMW wire from right femoral artery approach, successful wiring was done from totally occluded LM to distal LAD. Predilation was performed with Mercury 2.0 x 14mm (10 atm/ 10 sec) at the LM to proximal LAD. (Figure 4) Fortunately, whole left coronary artery system was visualized. (Figure 5, Figure 6) After dual wiring into LAD & LCX, 3 overlapping Taxus stents were successfully deployed from mid LAD to LM; Taxus 2.5 x 24 mm (16 atm/10sec), Taxus 2.75 x 16 mm (12 atm/10 sec), and Taxus 3.5 x 24 mm (14 atm/10 sec). (Figure 7, Figure 8, Figure 9, Figure 10) After LM to proximal LAD stenting, the ostium of LCX was significantly jailed, and then that lesion was sequentially dilated with Ryujin 1.5 x 15 mm (18 atm/15 sec) and Mercury 2.0 x 14 mm (10 atm/10 sec). (Figure 11) Final sequential kissing balloon was done with Yangtze 3.0 x 15 mm (LM to proximal LAD, 12 atm/20 sec) and Mercury 2.0 x 15 mm (12 atm/25 sec). (Figure 12) Additional ballooning was done with Quantum Maverick 3.5 x 8 mm. (Figure 13) Final angiogram showed excellent patency in whole left coronary artery. (Figure 14, Figure 15) Post PCI IVUS finding showed well expanded stent. (Figure 16, Figure 17)

Two days after the index procedure, patient developed acute ischemic chest pain and ECG change (ST depression in II, III, and aVF). CK-MB was elevated to 8.31 ng/ml. Emergency coronary angiography showed thrombotic total occlusion at the proximal LAD, showing subacute stent thrombosis with repeat NSTEMI. (Figure 18)

After successful guidewire passage, simple sequential balloon dilation was performed with Stormer 2.0 x 15 mm (8 atm/10 sec) and Quantum 3.0 x 12 mm (18 atm/10 sec). (Figure 19, Figure 20) Reopro (Gp IIb/IIIa receptor blocker) infusion was started with the repeat PCI. Final angiogram showed excellent angiographic patency with good distal run-off from LM to distal LAD. (Figure 21)

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Comments

  • Hassan Khalaf 2008-02-01 In the second event . I will consider CABG.
  • Marcelo Ribeiro 2008-02-04 In a pro thrombotic environment I think this would already be a case to start with Gp IIb/IIIa inhibitors, and also the excessive stent length(more or less 60 mm, considering some overlap ) with drug eluting stents, at least at the present time is a very risky approach- I had a similar case, done with bare metal stents, and after 4 months fwp the left main result was ok, although restenosis occurred at the two stents at the LAD, perhaps signalizing the diferent, better results of bare metal stents at the culprit AMI lesion, where thrombus may be a predominant factor.
  • Varin Arora 2008-02-10 Would a kissing stent technique be better aproach for left main/LAd /Lcx intervention VA
  • Oliver Kalpak MD 2008-02-18 I is High Risk Intervention, why not use Reopro; IVUS .
  • Antonia Anna Lukito 2008-02-18 I absolutely agree with Marcello's comment, and one more thing, how is the clopidogrel dosing before & after procedure?
  • Yean Teng Lim 2008-02-23 In addition to what has been mentioned, what about choice of stents? Is DES the best option in patients with significant thrombus load or pro-thrombotic state as in this case? There is now data which suggests that while we want the long term benefit of DES stenting at left main and LAD in this case, we will have to deal with complications exactly as in this case. Pro-healing stent (genous) might be an option - but its late loss is a compromise between DES & BMS. Bare metal stents in acute situation like this is an alternative. If it restenose - CABG would be an option.
  • dr.chucs 2008-03-01 I agree with the comments from Antonia Anna Lukito above that in this high-risk case of subacute stent thrombosis, esp. the culprit lesion is located over the critical LM to Prox. LAD, aggressive anti-platelet dual therapy in combination with Gp IIb/IIIa should be applied immediately after the apparently successful procedure in the first place. 2nd episode of recurrent occlusion will bring further dangerous impact on this poor lady again. Always thinking about the adjunctive therapy after successful PCI procedure in high-risk patient, otherwise the success just can not lasts longer!
  • shafique 2008-03-01 it would have been much better strategy to start with GPIIb/ IIIa inhibitor right earlier especially in the setting of multi stenting and acute coronary syndrome.
  • shafique 2008-03-01 it would have been much better strategy to start with GPIIb/ IIIa inhibitor right earlier especially in the setting of multi stenting and acute coronary syndrome.
  • Seung-Woon Rha 2008-03-09 I'm Dr Rha and Thank you for the comments. Basically, I performaing all the left main intervention under the IVUS guidance. For the antithrombotics and antiplatelet regimen, we routinely use administration of LMWH before PCI, UFH (50u/kg) during the PCI and loading of triple antiplatelets before PCI (aspirin 200mg, plavix 600mg, pletaal 200mg). Because the GpIIbIIIa blocker can not be reimmbursed in Korean society without visible active thrombi, we routinely can not use mainly because of the economic problem. Thus, we try to cover strong antithrombotics and intensive triple antiplatelet regimen. Still we have 3 commercially available DESs (cypher, Taxus & Endeavor) but other newer DESs are pending... Regarding technical issues, if the baseline LCX os is stenotic greater than 50% stenosis, I prefer to do the two stents strategy, but if the LCX is not so significant, I usually do the Stent Crossover strategy and further, sometimes refer the FFR measurements. Now patient is fine and regulary under OPD follow up.
  • omar shibly 2008-03-09 It would be much better CABG from the beginning rather than PCI economically( as you mentioned finance problem restricttion ) and for the patient it self as anytime she is haunted by another thrombotic event and restenosis.
  • Takaaki Shiono 2008-03-15 Does she have an Aortitis (Takayasu disease) ?
  • Soon Chao Yang 2008-03-16 Thanks Dr Rha for an interesting case. Think u ve done ur best for this complex LM, LAD, LCx case. 1. Agree that CABG would have been the first choice Rx. However, I understand in Korea, just like many East Asia countries, patients are less receptive to CABG. 2. Don't think the type of stent chosen will make a lot of difference in this case. It is long lesion, relative small diameter (<3.0mm) and an ACS presentation... all pointing to increase stent thrombosis risk. 3. Agree that G2b-3a inhibitor would be essential in this case. In addition, should consider treating with Prasugrel (more potent antithrombotic) in the acute phase or higher maintanence clopidorgrel dosage (150mg for first 3-6 months) 4. Other thing to consider is the increasingly recognised antiplatelet resistance. While no definite data yet, not unreasonable to test in someone like her with very high risk of stent thrombosis for both aspirin and clopidrogrel resistance. If strong resistance, to give higher dosage of respective antiplatelet.
  • Gamal Abu-Omar 2008-05-01 Congratulations for this excellent case. However, the site of in-stent thrombosis is located in the mid LAD stent (Taxus 2.75 x 16 mm deployed at 12 atm/10 sec) which is clearly low pressure for good apposition and this is evident in the IVUS picture in the mid LAD and final angiogram.

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