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TCTAP C-065 Successful Percutaneous Coronary Intervention of a Complex Left Main Trifurcation Lesion
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S155
Relevant clinical history and physical exam. A 60-year-old male, with a history of Type 2 DM, Hypertension had presented with a 1-week history of effort angina progressing to rest angina. His ECG was unremarkable and Echocardiography was essentially normal. Relevant test results prior to catheterization. Relevant catheterization findings. CAG showed significant mid shaft LMCA disease. [INTERVENTIONAL MANAGEMENT] Procedural step. A 3.5 EBU catheter was used, 0.014 BMW wire crossed to LAD, a 3.5 x 12 DES was positioned across LMCA and dilated at 16 atmospheres. Post dilatation with 4.0 x 8 non-compliant NC balloon at 16 atmospheres showed good result. A run of OCT was done across the LMCALAD, the stent in LMCA showed not well-apposed stent hence OCT was removed and a 4.5 x 9 non-compliant NC balloon was crossed across stent and well post-dilated. A final run of OCT showed well post dilated stent struts, there was no carinal pinch and no hemodynamic abnormalities.
Case Summary. Though LMCA mid shaft stenting may look easy but a dissection look alike lesion can give many worries, quick stenting with a backup of OCT guidance and post-dilatation can indeed give good results. TCTAP C-065 Successful Percutaneous Coronary Intervention of a Complex Left Main Trifurcation Lesion Woohyeun Kim,1 Seung-Woon Rha1 Korea University Guro Hospital, Korea (Republic of)
1
[CLINICAL INFORMATION] Patient initials or identifier number. KSB Relevant clinical history and physical exam. A 57-year-old male presented with typical effort chest pain. He was ex-smoker and had a history of hypertension and hyperlipidemia. He also had a history of stable angina treated with percutaneous coronary intervention (PCI) in a proximal right coronary artery (RCA) five years ago and mid RCA 10 months ago. Relevant test results prior to catheterization. EKG showed normal sinus rhythm without ST-T changes. Two-dimensional echocardiography showed normal left ventricular function without regional wall motion abnormality. Treadmill test was done and it showed significant down slope ST-depression with T wave inversion at stage 2. Maximum workload was 5.40 METS. Relevant catheterization findings. Coronary angiography (CAG) revealed eccentric severe stenosis in mid left main (LM) to the ostium of a left anterior descending artery (LAD) which was very tortuous, angulated and calcified. Previous stent was patent without in-stent restenosis (ISR) in proximal and mid RCA. The lesion of LM to LAD was progressed, compared with the last CAG. [INTERVENTIONAL MANAGEMENT] Procedural step. A 7Fr JL 4.0 SH guiding catheter engaged into LCA via right femoral artery. Under Crusade microcatheter support, Sion blue guidewire inserted to ramus and Sion black guidewire was inserted to LAD via the side port of Crusade microcatheter after several attempts. However, during retrieval of Crusade microcatheter, the wire in LAD accidentally removed together. Unfortunately, same maneuver could not lead successful rewiring. Along with Fin cross microcatheter support, LM to LAD wiring successfully done by reversed wire technique. After successful wiring, target lesion sequentially predilated with multiple balloon. Because the lesion was too tortuous and calcified, we tried to deliver a stent by balloon anchoring at LCX. However, the stent could not pass the lesion. We changed the stent to shorter one to pass the lesion. Nevertheless, it also could not pass.
S156
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
We left the guidewire in LAD and tried to change a guiding catheter to extra backup support. We approached via left femoral artery using a 7Fr EBU 3.5 guiding catheter. After successful parallel wiring to LM to distal LAD with Sion black under EBU guiding catheter. We removed the previous Judkins guiding catheter. To enhance access to the lesion and provide additional backup support, we tried ‘child-in-mother’ technique using the Guidezilla guide extension catheter. After successful wiring with Grand slam to achieve maximal wire support, serial predilation was repeatedly done. Finally, we deployed the stent successfully.
Case Summary. Because the anatomy of the lesion was very tortuous and calcified, it was more difficult to do wiring and deliver the stent to the lesion. To tackle severely angulated lesion for safe wiring, we used Crusade microcatheter and “Reverse wire technique”. And, to enhance access to the lesion and provide maximal back-up support, we tried parallel wiring, anchor balloon technique and finally “child-in-mother technique”. Because a long stent might be impossible to pass the very tough lesion, we decided to deploy two short stents instead of deploying a long stent. TCTAP C-066 Two-stage Triple Double-kissing Crush Technique in a Patient with Multiple Bifurcation Lesions Shih-Hung Chan1 Section of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. Chen Relevant clinical history and physical exam. A 62 year-old male with hypertension and hyperlipidemia presented with crescendo angina pectoris. Treadmill exercise test revealed positive result for myocardial ischemia. Renal function and left ventricular systolic performance are normal. Physical examination did not reveal remarkable abnormal finding. Relevant test results prior to catheterization. Treadmill exercise test: positive for myocardial ischemia Echocardiography: Adequate LV systolic performance with LVEF 64% Multi-slice coronary CTA: 1. The calcium score is 89.0 2. LM-3VD showing multifocal plaques and stenosis with a) 50-69% stenosis at distal LM b) Near 90% stenosis at dLCX c) >70% stenosis at mRCA, dRCA, pLAD, D1 branch and pLCX d) 50-69% stenosis at pRCA, mLAD and OM branch
S155
Relevant clinical history and physical exam. A 60-year-old male, with a history of Type 2 DM, Hypertension had presented with a 1-week history of effort angina progressing to rest angina. His ECG was unremarkable and Echocardiography was essentially normal. Relevant test results prior to catheterization. Relevant catheterization findings. CAG showed significant mid shaft LMCA disease. [INTERVENTIONAL MANAGEMENT] Procedural step. A 3.5 EBU catheter was used, 0.014 BMW wire crossed to LAD, a 3.5 x 12 DES was positioned across LMCA and dilated at 16 atmospheres. Post dilatation with 4.0 x 8 non-compliant NC balloon at 16 atmospheres showed good result. A run of OCT was done across the LMCALAD, the stent in LMCA showed not well-apposed stent hence OCT was removed and a 4.5 x 9 non-compliant NC balloon was crossed across stent and well post-dilated. A final run of OCT showed well post dilated stent struts, there was no carinal pinch and no hemodynamic abnormalities.
Case Summary. Though LMCA mid shaft stenting may look easy but a dissection look alike lesion can give many worries, quick stenting with a backup of OCT guidance and post-dilatation can indeed give good results. TCTAP C-065 Successful Percutaneous Coronary Intervention of a Complex Left Main Trifurcation Lesion Woohyeun Kim,1 Seung-Woon Rha1 Korea University Guro Hospital, Korea (Republic of)
1
[CLINICAL INFORMATION] Patient initials or identifier number. KSB Relevant clinical history and physical exam. A 57-year-old male presented with typical effort chest pain. He was ex-smoker and had a history of hypertension and hyperlipidemia. He also had a history of stable angina treated with percutaneous coronary intervention (PCI) in a proximal right coronary artery (RCA) five years ago and mid RCA 10 months ago. Relevant test results prior to catheterization. EKG showed normal sinus rhythm without ST-T changes. Two-dimensional echocardiography showed normal left ventricular function without regional wall motion abnormality. Treadmill test was done and it showed significant down slope ST-depression with T wave inversion at stage 2. Maximum workload was 5.40 METS. Relevant catheterization findings. Coronary angiography (CAG) revealed eccentric severe stenosis in mid left main (LM) to the ostium of a left anterior descending artery (LAD) which was very tortuous, angulated and calcified. Previous stent was patent without in-stent restenosis (ISR) in proximal and mid RCA. The lesion of LM to LAD was progressed, compared with the last CAG. [INTERVENTIONAL MANAGEMENT] Procedural step. A 7Fr JL 4.0 SH guiding catheter engaged into LCA via right femoral artery. Under Crusade microcatheter support, Sion blue guidewire inserted to ramus and Sion black guidewire was inserted to LAD via the side port of Crusade microcatheter after several attempts. However, during retrieval of Crusade microcatheter, the wire in LAD accidentally removed together. Unfortunately, same maneuver could not lead successful rewiring. Along with Fin cross microcatheter support, LM to LAD wiring successfully done by reversed wire technique. After successful wiring, target lesion sequentially predilated with multiple balloon. Because the lesion was too tortuous and calcified, we tried to deliver a stent by balloon anchoring at LCX. However, the stent could not pass the lesion. We changed the stent to shorter one to pass the lesion. Nevertheless, it also could not pass.
S156
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
We left the guidewire in LAD and tried to change a guiding catheter to extra backup support. We approached via left femoral artery using a 7Fr EBU 3.5 guiding catheter. After successful parallel wiring to LM to distal LAD with Sion black under EBU guiding catheter. We removed the previous Judkins guiding catheter. To enhance access to the lesion and provide additional backup support, we tried ‘child-in-mother’ technique using the Guidezilla guide extension catheter. After successful wiring with Grand slam to achieve maximal wire support, serial predilation was repeatedly done. Finally, we deployed the stent successfully.
Case Summary. Because the anatomy of the lesion was very tortuous and calcified, it was more difficult to do wiring and deliver the stent to the lesion. To tackle severely angulated lesion for safe wiring, we used Crusade microcatheter and “Reverse wire technique”. And, to enhance access to the lesion and provide maximal back-up support, we tried parallel wiring, anchor balloon technique and finally “child-in-mother technique”. Because a long stent might be impossible to pass the very tough lesion, we decided to deploy two short stents instead of deploying a long stent. TCTAP C-066 Two-stage Triple Double-kissing Crush Technique in a Patient with Multiple Bifurcation Lesions Shih-Hung Chan1 Section of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. Chen Relevant clinical history and physical exam. A 62 year-old male with hypertension and hyperlipidemia presented with crescendo angina pectoris. Treadmill exercise test revealed positive result for myocardial ischemia. Renal function and left ventricular systolic performance are normal. Physical examination did not reveal remarkable abnormal finding. Relevant test results prior to catheterization. Treadmill exercise test: positive for myocardial ischemia Echocardiography: Adequate LV systolic performance with LVEF 64% Multi-slice coronary CTA: 1. The calcium score is 89.0 2. LM-3VD showing multifocal plaques and stenosis with a) 50-69% stenosis at distal LM b) Near 90% stenosis at dLCX c) >70% stenosis at mRCA, dRCA, pLAD, D1 branch and pLCX d) 50-69% stenosis at pRCA, mLAD and OM branch