Select Page

Case 3: OCT Guided Complex Intervention Of LM And Long Calcified Aneurysmal LAD

Case Presentation

  • A 76-year-old woman presented with angina like chest pain and dyspnea on exertion.
  • Stress MPI showed lateral ischemia.
  • Medical history : HTN, HLD, Gout
  • Medications: Aspirin, Amlodipine, Metoprolol XL, Losartan, Atorvastatin, Allopurinol
  • Coronary angiogram revealed left main disease and long calcified, aneurysmal lesion in LAD.
  • Planned to undergo imaging guided complex LAD PCI.

Case Planning

OCT of LM

LM (MLA) = 4.46 mm2 (no calcium)

OCT of LAD

LAD (MLA)= 1.47 mm2 (4 quadrant calcium)

PCI Strategy

  • 7F guide catheter
  • With the presence of severely calcified disease, planned to use atherectomy for lesion preparation.
  • Initial wire choice: Runthrough and FineCross microcatheter
  • Imaging guided PCI, 2 stents vs provisional strategy
  • If provisional strategy used, planned to use a jailed side branch wire (i.e. Fielder wire)1
  1. Pan M et al. Structural Damage of Jailed Guidewire During the Treatment of Coronary Bifurcation Lesions: A Microscopic Randomized Trial. JACC Cardiovasc Interv. 2016;9(18):1917-1924.doi:10.1016/j.jcin.2016.06.030

STEPS

  • The initial choice of wire was Runthrough (180 cm) with FineCross microcatheter. Then, Rota Floppy wire will be exchanged via FineCross, followed by rotational atherectomy (1.75 Burr) of LAD.
  • Fielder wire was placed in LCx along with Runthrough wire in LAD.
  • One DES(Xience 3.2/38) was placed in mid LAD.
  • Another DES (Xience 3.5/23) was placed from LM to LAD while jailing Fielder wire (Polymer jacketed wire) in LCx.

Runthrough and Fine Cross > ROTA Floppy Wire

Bifurcation (2 wires)

  • After DES placement in LM to LAD, the ostium of LCx was jailed.
  • A kissing balloon inflation was performed in LAD (3.0 compliance balloon) and LCx (3.0 compliance balloon).
  • Post OCT showed stent malapposition at the aneurysm area and further optimization was done with NC balloon 4.0/8mm.

Final Angiogram

Learning Points

  • In a long calcified lesion, exchanging Rotawire via FineCross is a better option than direct wiring with Rota wire.
  • In Bifurcation PCI, polymer-coated wires (Fielder, Whisper MS) should be placed in jailed side branch (bifurcation stenting) as this could alleviate wire damage.1
  • Imaging guided PCI is recommended in LM/LAD disease to delineate whether two stents or provisional strategy.
  • To navigate through an aneurysm, the wire should have hydrophobic coated (better tactile feedback), a stiffer tip, and excellent torqueability. Runthrough was able to negotiate the lesion in this case. Other wires choice should be Gaia series and MiracleBros along with a microcatheter.
  1. Pan M, Ojeda S, Villanueva E, et al. Structural Damage of Jailed Guidewire During the Treatment of Coronary Bifurcation Lesions: A Microscopic Randomized Trial. JACC Cardiovasc Interv. 2016;9(18):1917-1924. doi:10.1016/j.jcin.2016.06.030

Left Main DK Crush Video ID