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Case 23: Simple Lesion

Case Presentation

  • A 60-year-old man presented with new onset left sided chest pain on exertion and relieved by rest. Stress MPI showed mild-moderate anteroseptal and inferior ischemia. Echocardiogram showed normal LVEF with 56%.
  • Medical History: Hypertension, Hyperlipidemia, End-Stage renal disease on hemodialysis, Ex-smoker
  • Medications: ASA 81mg daily, Amlodipine 10mg daily, Carvedilol 3.125mg BID, Hydralazine 25mg TID

Angiogram

Angiogram

PCI Strategy

  • The coronary angiogram showed a significant disease in ramus artery with 80-90% stenosis.
  • Since the lesion is not calcified or tortuous, it can be classified as ACC/AHA Type A lesion (simple lesion).
  • Plan to use workhorse wire, followed by predilation and stent placement.

STEPS

  • We used VL 3.5 guide catheter (Mach 1: Boston Scientific).
  • For Type A lesion, we can use any workhorse wire which has a soft tip with hybrid coating (hydrophilic coating with distal hydrophobic coating) (i.e. Runthrough, Sion Blue).
  • We used Runthrough to cross the lesion, followed by predilatation using Trek NC 3/12mm balloon.
  • Then, Xience Sierra 3.25/18mm was placed in the ramus artery followed by post-dilatation using Trek NC 3.5/12 mm balloon.
  • A final angiogram showed an excellent result.

Learning Points

  • In Type A lesion intervention, the goal is to cross the lesion and advance the wire to the distal lumen softly and atraumatically.
  • Any workhorse wire can be used per the operator’s preference to perform the coronary intervention.

Left Main DK Crush Video ID