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TCTAP C-048 Treatment of Distal Left Main True Bifurcation Involving LAD CTO Lesion by the Retrograde Approach and Culotte Stenting
S134
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Lesion finally crossed withMiracle-3 wire using balloon support. Lesion dilated with 1.25X8 mm CTO balloon and 2.0X15 mm Sprinter Legend balloon. Xience-V 2.75X28 mm stent deployed successfully in distal RCA with normal flow through and beyond stent. TIMI – III flow achieved. 40% residual stenosis remained distal to stent at crux and PLV.
Case Summary. Anomalously arising coronary arteries, if have slit like orifice, or acute angulation, or if they run between aorta and RVOT definitely have more malignant outcome. These are more prone to atherosclerosis than normally arising coronaries. (CASS Registry) The possibility of anomalous coronaries should always be kept in mind while performing PCI and necessary hardware must be available in dealing such situations. If small caliber side branch gets compromised without signs and symptoms during PCI, it should be managed conservatively.
TCTAP C-048 Treatment of Distal Left Main True Bifurcation Involving LAD CTO Lesion by the Retrograde Approach and Culotte Stenting Yasuto Uchida,1 Kenji Wagatsuma,1 Hideo Nii1 Tsukuba Memorial Hospital, Japan
1
[CLINICAL INFORMATION] Patient initials or identifier number. I.I Relevant clinical history and physical exam. The subject was a 73-yearold male. On May18, 2014, he underwent emergency CAG based on the diagnosis of AMI. The RCA# 1 was totally occluded, and LMT bifurcation lesion including a total occlusion of the LAD#6 ostium was revealed. After determining from CAG findings and ECG findings that RCA #1 was the culprit lesion, PCI was immediately performed, and the treatment was successful. With good prognosis after AMI, PCI was performed on the left coronary artery on December 25, 2014. Relevant test results prior to catheterization. Blood samples before PCI revealed brain natriuretic peptide (BNP) to be101pg/ml, but other than this there were no notable abnormalities, and the originally revealed heart failure showed improvement. For left ventricular function, echocardiography revealed ejection fraction of 49%, severe hypokinesis of the inferior wall from the basal portion to the apex, and moderate hypokinesis of the posterior wall from the basal portion to midportion. No definite valvular disease was revealed. Relevant catheterization findings. Right dominant circulation LMT: 50-75% stenosis of distal LMT RCA: RCA#1 stented with 3.524mm NOBORI, and #2 with 4.022mm Integrity
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S135
LAD: LAD #6 had a chronic total occlusion(CTO) of the ostium, and good collateral circulation from seen from RCA 4PD via the septal branch. LCx: 50-75% stenosis of LCx #11 ostium; 75%stenosis from #11 distal to #13 [INTERVENTIONAL MANAGEMENT] Procedural step. Taking the bi-radial approach, Using RCA 90cmHeartrail AL 1.0 SH7Fr and LCA Mach 1 Voda Left 3.5 SH 7Fr guiding catheters. First, PCI was attempted by the retrograde approach. Via the septal branch, using Corsair ⓇþSION, the guide wire was passed to directly under the #6 occlusion. Using the wire as a landmark, attempts were made to cross the lesion antegrade with CaravelⓇþXT-R. However, this was difficult, and passage failed even after change from Gaia 1stto Gaia 2nd. Gaia 1st followed by Gaia 2nd were then used to attempt retrograde wire crossing, but also faced difficulty. When the antegrade wire was changed to Conquest Pro, re-entry to the true lumen from the false lumen from the distal CTO portion became possible. The microcatheter was advanced, changed torsion, and the wire was successfully crossed. As a lesion was also revealed inLCx#13 after POBA of #6-7, #6, #7, #13 were respectively stented with Resolute Integrity 3.0/15mm, XIENCE Xpedition 2.5/28mm, and Resolute Integrity 2.75/18mm. The LMT was a true bifurcation, and because IVUS showed the wire passing through the subintima from the LAD #6 CTO entry site, the policy was taken to first place a stent in the LCx, with the selection of culottes tenting. Resolute Integrity 3.0/26mm was placed in LMT #11, a ResoluteIntegrity 3.0/26mm was placed in LMT-LAD #6. Finally, both stents were expanded at the same time and good dilatation was achieved.
Case Summary. In this case, the reverse CART technique was considered, but IVUS showed the antegrade wire passing through a false lumen from under the #6 ostium. As there was a possibility that POBA could cause occlusion of the LCx. Mini-crush stenting giving priority to the LAD could cause LCx occlusion when the LMT-LAD portion is dilated. In this subject, we performedculotte stenting that gave priority to the patent LCx, but there is a sizeablepossibility that in such a case, difficulty will be encountered in rewiring tothe LAD. In this case, we were consequently able to treat the LMT bifurcationwhile consistently maintaining the patency of the LCx.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Lesion finally crossed withMiracle-3 wire using balloon support. Lesion dilated with 1.25X8 mm CTO balloon and 2.0X15 mm Sprinter Legend balloon. Xience-V 2.75X28 mm stent deployed successfully in distal RCA with normal flow through and beyond stent. TIMI – III flow achieved. 40% residual stenosis remained distal to stent at crux and PLV.
Case Summary. Anomalously arising coronary arteries, if have slit like orifice, or acute angulation, or if they run between aorta and RVOT definitely have more malignant outcome. These are more prone to atherosclerosis than normally arising coronaries. (CASS Registry) The possibility of anomalous coronaries should always be kept in mind while performing PCI and necessary hardware must be available in dealing such situations. If small caliber side branch gets compromised without signs and symptoms during PCI, it should be managed conservatively.
TCTAP C-048 Treatment of Distal Left Main True Bifurcation Involving LAD CTO Lesion by the Retrograde Approach and Culotte Stenting Yasuto Uchida,1 Kenji Wagatsuma,1 Hideo Nii1 Tsukuba Memorial Hospital, Japan
1
[CLINICAL INFORMATION] Patient initials or identifier number. I.I Relevant clinical history and physical exam. The subject was a 73-yearold male. On May18, 2014, he underwent emergency CAG based on the diagnosis of AMI. The RCA# 1 was totally occluded, and LMT bifurcation lesion including a total occlusion of the LAD#6 ostium was revealed. After determining from CAG findings and ECG findings that RCA #1 was the culprit lesion, PCI was immediately performed, and the treatment was successful. With good prognosis after AMI, PCI was performed on the left coronary artery on December 25, 2014. Relevant test results prior to catheterization. Blood samples before PCI revealed brain natriuretic peptide (BNP) to be101pg/ml, but other than this there were no notable abnormalities, and the originally revealed heart failure showed improvement. For left ventricular function, echocardiography revealed ejection fraction of 49%, severe hypokinesis of the inferior wall from the basal portion to the apex, and moderate hypokinesis of the posterior wall from the basal portion to midportion. No definite valvular disease was revealed. Relevant catheterization findings. Right dominant circulation LMT: 50-75% stenosis of distal LMT RCA: RCA#1 stented with 3.524mm NOBORI, and #2 with 4.022mm Integrity
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S135
LAD: LAD #6 had a chronic total occlusion(CTO) of the ostium, and good collateral circulation from seen from RCA 4PD via the septal branch. LCx: 50-75% stenosis of LCx #11 ostium; 75%stenosis from #11 distal to #13 [INTERVENTIONAL MANAGEMENT] Procedural step. Taking the bi-radial approach, Using RCA 90cmHeartrail AL 1.0 SH7Fr and LCA Mach 1 Voda Left 3.5 SH 7Fr guiding catheters. First, PCI was attempted by the retrograde approach. Via the septal branch, using Corsair ⓇþSION, the guide wire was passed to directly under the #6 occlusion. Using the wire as a landmark, attempts were made to cross the lesion antegrade with CaravelⓇþXT-R. However, this was difficult, and passage failed even after change from Gaia 1stto Gaia 2nd. Gaia 1st followed by Gaia 2nd were then used to attempt retrograde wire crossing, but also faced difficulty. When the antegrade wire was changed to Conquest Pro, re-entry to the true lumen from the false lumen from the distal CTO portion became possible. The microcatheter was advanced, changed torsion, and the wire was successfully crossed. As a lesion was also revealed inLCx#13 after POBA of #6-7, #6, #7, #13 were respectively stented with Resolute Integrity 3.0/15mm, XIENCE Xpedition 2.5/28mm, and Resolute Integrity 2.75/18mm. The LMT was a true bifurcation, and because IVUS showed the wire passing through the subintima from the LAD #6 CTO entry site, the policy was taken to first place a stent in the LCx, with the selection of culottes tenting. Resolute Integrity 3.0/26mm was placed in LMT #11, a ResoluteIntegrity 3.0/26mm was placed in LMT-LAD #6. Finally, both stents were expanded at the same time and good dilatation was achieved.
Case Summary. In this case, the reverse CART technique was considered, but IVUS showed the antegrade wire passing through a false lumen from under the #6 ostium. As there was a possibility that POBA could cause occlusion of the LCx. Mini-crush stenting giving priority to the LAD could cause LCx occlusion when the LMT-LAD portion is dilated. In this subject, we performedculotte stenting that gave priority to the patent LCx, but there is a sizeablepossibility that in such a case, difficulty will be encountered in rewiring tothe LAD. In this case, we were consequently able to treat the LMT bifurcationwhile consistently maintaining the patency of the LCx.