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CASE 10: IVUS-guided PCI of ostial LM and proximal LAD lesions

Case Presentation

A 74-year-old male presented with worsening angina symptoms and shortness of breath on exertion to our hospital. He has a history of prior MI, hypertension, NIDDM, hyperlipidemia and has had multiple PCI procedures. Most recently, 5 years ago, DES were implanted mid RCA ISR (2.75mm x 28mm), proximal LAD (2.75mm x 16mm). Echocardiography showed good left ventricular systolic function (Ejection Fraction of 60%). A coronary angiogram showed 90-95% stenosis of the proximal LAD, 50% stenosis in the ostial LM, and 80-90% stenosis in the OM1.

Angio Pre

IVUS Pre

We first performed a PCI on OM1. Since there was no calcification on angiography, we performed pre-dilatation with a 2.5mm cutting balloon and deployed 2.5mm x 20mm DES to the lesion. Further evaluation was then performed for LAD-LM with IVUS. This revealed eccentric fibrous plaque at the proximal LAD and lipid rich lesions with attenuated plaque at the LM. The MLAs were 3.77mm2 and 4.84mm2, respectively. The lesion length from the ostial LM to the proximal LAD (proximal edge of old stent) was 24mm, therefore a 3.0mm x 28mm DES was deployed to the lesion. Repeat IVUS was performed following stenting. IVUS showed that the MSA was 6.7mm2 at the LAD and 9.4mm2 at the LM, with good dilatation and no malapposition or dissection.

Angio Post

IVUS Post

IVUS also showed a small stent protrusion into the aorta. This protrusion was shorter than 1mm and covered all the lesions in the ostial LM. Confirmation of full stent coverage is important when treating ostial lesions. While full coverage is important, it is also undesirable for the stent to protrude too far into the aorta in an ostial lesion, therefore precision is required when positioning the stent. For this reason, the short-axis image of the IVUS is sometimes used to mark the position of the stent on the contrast image, and the stent is placed.

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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