Case 19: Revascularization of Calcific LM Bifurcation and Aneurysmal pLAD
Case Presentation
- An 86-year-old woman presented with chronic stable angina CCS Class II and a positive MPI for anterior and lateral wall ischemia for 2 years. She was managed medically.
- Cardiac catheterization revealed severe calcific dLM bifurcation disease, prox LAD focal aneurysm, Syntax score 30 and LVEF 60%.
- She was recommended for CABG but declined by the patient & family due to old age and poor coordination.
- Prior History: Hypertension, Hyperlipidemia, Rt LE DVT
- Medications : Aspirin 81mg, Atorvastatin 40mg, Metoprolol Succinate 50mg, Apixaban 5mg twice daily, ISMN 60mg, Ranolazine 500mg twice daily
- Planned for complex intervention of calcific left main bifurcation with provisional stenting technique +/- rotational atherectomy and IVUS guidance
Angiogram
PCI Strategy
- Provisional Stenting Strategy
- Tentative 2 DES for two lesions (1 in LM and 1 in mid LAD)
- A workhorse wire in LCx and hydrophobic wire in LAD
- Rotational atherectomy in dLM
- Post PCI imaging (IVUS) and optimization accordingly
Case Review and Planning
STEPS
- With aneurysm segment in dLM and prox LAD, the wire should have hydrophobic coating with a stiffer tip to negotiate into the LAD.
- A good angiographic angle is paramount in this challenging anatomy and we used LAO 58/CAU 19 to tackle this lesion.
- First, we used a Runthrough wire to negotiate the LCx and IVUS was done.
- To negotiate the aneurysmal segment, we used MiracleBros 3 (Asahi) (11 cm hydrophobic coating, 3g tip load) along with FineCross microcatheter.
- Then, exchanged the MiracleBros to Rotawire Floppy and IVUS imaging was performed.
- IVUS of LM showed 360 degree of calcium in dLM and RA with 1.5 rota burr was performed.
Wiring Technique
Wiring Technique
STEPS
- Serial Balloon inflation was performed in dLM and LAD, followed by the placement of 2 DES (4/12) in LM and (3/24) in LAD with an excellent result, also verified with IVUS imaging.
- Modest reduction in the size of the LAD aneurysm was seen on post PCI angiogram.
Final Angiogram
The case can be reviewed at https://ccclivecases.org/january-2019-ccc-live-case
Learning Points
- Navigating through an aneurysm is quite challenging and requires appropriate wire selection and equipment.
- Although it is easy to enter into an aneurysm segment, the wire mostly will coil up inside the aneurysm.
- To negotiate through an aneurysm, it often requires a wire with hydrophobic coated and a stiffer tip (better tactile feedback and excellent torqueability), along with a microcatheter for additional support.
- The wire that we used, in this case, was MiracleBros 3 wire.
- In some cases, it may even need angulated catheter to navigate through an aneurysm (i.e. Supercross 90/120).
- A microcatheter (FineCross in this case) is useful not only for a better wire support but also for wire exchange.
- Pre and post imaging guided PCI optimization is highly recommended in these challenging left main PCI case.
