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

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

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.

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