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CASE 12: IVUS-guided LAD stent sizing

CASE 12: IVUS-guided LAD stent sizing

Case Presentation

A 73-year-old male had presented with angina on exertion to our hospital. SPECT-MPI test showed apical and lateral wall ischmeia. He had a history of hypertension, dyslipidemia, ESRD (on dialysis), and paroxysmal atrial fibrillation. Echocardiography showed good left ventricular systolic function (Ejection Fraction of 60%). A coronary angiogram showed 90% stenosis of the mid LAD.

Angio Pre

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IVUS Pre

The landing zone of the stent should ideally be in a healthy area where there is no plaque. Sometimes there is no truly healthy area proximal to the lesion. The landing zone should then be the area where the plaque burden is less than 50%. To select the stent size, the mean lumen diameter of the reference at the proximal or distal part of the lesion should be used, and a balloon or stent size equal to or slightly larger (with up rounding to the nearest 0-0.25mm stent) than that should be considered. Alternatively, measure the average vessel diameter (EEL-EEL) distal to the lesion and proximal to the lesion, and choose a balloon or stent of a slightly smaller size (with down rounding to the nearest 0.25mm stent size).¹

In this case, IVUS images showed eccentric fibrous plaque in the lesion. The mean vessel diameter at the distal part of the lesion was 3.3mm and the lesion length was 26mm. The MLA was 2.77mm². Therefore, we choose a 3.0mm x 28mm DES. The mean vessel diameter at the proximal part of the lesion was 3.84mm, then we performed post-dilation with a 3.5mm non-compliant (NC) balloon up to 14 atm. Repeat IVUS images showed that the stent was well expanded, and no malapposition and no stent edge dissection was observed. The MSA was 6.37mm².

Angio Post

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IVUS Post

Raber L. Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions. Eur Herat J. 2018;39:3281-3300.