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CASE20191114_015
| CORONARY - Bifurcation/Left Main Diseases and Intervention | |
| Optical Coherence Tomography Guided Left Circumflex and Obtuse Marginal Artery Bifurcation Stenting in a Previous Simultaneous Kissing Stenting of Left Main | |
| Sreenivas Reddy1, Raghavendra Rao K2, Jeetram Kashyap2, Suraj Kumar2 | |
| Post Graduate Institute Of Medical Education And Research, India1, Government Medical College and Hospital, India2, | |
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[Clinical Information]
- Patient initials or identifier number:
DVS
-Relevant clinical history and physical exam:
56 years old hypertensive male presented to the emergency services with complaints of acute onset retrosternal chest pain. Clinical examination revealed a normal pulse rate and blood pressure. Jugular venous pulse and the cardiovascular examination were unremarkable. His past history was significant as had undergone left main bifurcation simultaneous kissing stenting (SKS) 2 years back.
 (S1_F1-56).avi (S2_F1-43).avi (S5_F1-39).avi-Relevant test results prior to catheterization:
Blood investigations such as hemoglobin, platelets and renal function tests were within normal limits. ECG showed normal sinus rhythm with ST-T wave changes in the anterolateral leads. Echocardiography revealed regional wall motion abnormality in left circumflex artery territory with mild LV systolic dysfunction (EF 45-50%).
(S6_F1-39).avi (S7_F1-101).avi (S9_F1-45).avi- Relevant catheterization findings:
Coronary angiography showed patent stents in the left main coronary artery with mild in-stent restenosis in the LAD stent. LCX stent was patent with proximal to distal diffuse disease, OM major also had significant disease in the ostio-proximal region making it a LCX and OM major bifurcation lesion (MEDINA 1,1,1).
(S11_F1-50).avi (S18_F1-77).avi (S21_F1-93).avi |
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[Interventional Management]
- Procedural step:
Left main engaged using Judkins Left guide catheter (7French,3.5) via transfemoral route.Coronary guide wire 0.014¡¯¡¯ Asahi Sion Blue (Asahi Intecc, Japan) placed in LCX and OM major Lesions in LCX and OM major were predilated using 2.5 x 15 mm semi-compliant balloon (SC) at 12-14 ATM.A stent Xience Prime 3 x 28 mm (Abott Vascular, CA, USA) deployed in distal LCX at 12 ATM.A stent Xience Prime 2.75 x 23 mm (Abott Vascular, CA, USA) was positioned in OM major with a 2.5 x 15 mm NC balloon placed in LCX across the bifurcation.The stent was deployed in OM major at 12 ATM and the stent struts were crushed with the balloon place in LCX (STEP CRUSH TECHNIQUE).The stent delivery system and wire removed from OM major.A stent Xience Prime 3.5 x 23 mm (Abott Vascular, CA, USA) was deployed in proximal to distal LCX overlapping with the first stent in LCX and crushing the stent of OM major.The stent in LCX was postdilated using 3.5 x 9 mm NC balloon at 10-18ATM.An 0.014'' Asahi Sion Blue wire (Asahi Intecc, Japan) was recrossed through the stent struts into OM major. The stent in OM major was post dilated with a 3 x 9 mm NC balloon at14-18 ATM.Final kissing balloon inflation was done using 3 x 9 mm NC balloon in OM major and 3.5 x 9 mm balloon in LCX at nominal pressure.Proximal optimisation was done using 4 x 9 mm NC balloon at 14-18ATM.OCT pull back at the end of procedure was satisfactory.
(S22_F1-83).avi (S27_F1-98).avi TCTAP LCX OM.avi- Case Summary:
Treating downstream lesions after a left main simultaneous kissing stenting can be technically challenging but feasible.Caution has to be taken by the operator to ensure that the coronary guidewires are in the correct limbs of the stented segments.Anchor - Balloon technique can be used to facilitate the crossing of balloons in to the side branch. Intracoronary imaging modalities play a vital role.
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