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  3. Case 19: Revascularization of Calcific LM Bifurcation and Aneurysmal pLAD

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

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.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

Left Main DK Crush Video ID