Case 4: Bifurcation lesion of LAD and LCX with severe calcified nodule with ulcerated plaque in LMT, 2 stent strategy (Mini-Crush technique)
81-year-old male with progressive worsening DOE and recent admission at outside hospital with hypertensive crisis and pulmonary edema. Coronary CTA showed 3V CAD with positive CTFFR and referred to our hospital for further coronary assessment. He has a history of hypertension, NIDDM, hyperlipidemia. Echocardiography showed normal left ventricular wall motion with ejection fraction of 60%.
CAG showed 70-80% stenosis at the distal LMT, 70-80% stenosis at the proximal LAD and mid LAD, and 80-90% stenosis at the proximal LCX, including ulcer-like plaque in the LMT. IVUS images showed ulcerated plaque and calcified nodule in the LMT. Also there was a severe calcified plaque in the proximal LAD and severe calcified plaque and fibrous plaque in the proximal LCX. The mid LAD could not be observed by IVUS due to insertion difficulty, but angiographic findings were suggestive of severe calcification. The MLA was 3.7mm², 3.5mm², and 3.1mm² for LMT, LAD, and LCX, respectively. Therefore, we decided to perform lesion modification with a rotational atherectomy first, and ablation was performed with a 1.5mm burr for the mid LAD and a 1.75mm burr for the proximal LAD, proximal LCX, and LMT.
Angio Pre CAU run5
IVUS Pre LCX-LMT run1
IVUS Pre LAD-LMT run6
Then, the lesion in the mid LAD was pre-dilated with 3.0mm non-compliant (NC) balloon and a 3.0mm x 33mm DES was deployed. The stent was post-dilated with 3.0mm NC balloon up to 24atm. Subsequently, lesion in the LMT distal and proximal LCX were pre-dilated with 3.5mm NC balloon and lesion in the proximal LAD was pre-dilated with 3.0mm NC balloon. Then 3.5mm x 18mm DES and 3.5mm x 8mm DES were placed across the proximal LAD and proximal LCX respectively and mini-crush technique was performed. Finally KBI were performed with 3.5mm and 3.0mm NC balloons. The MSA were 16.6mm², 10.9mm², and 7.4mm² for LMT, LAD, and LCX, respectively.
IVUS Post LAD-LMT run11
IVUS Post LAD-LMT run22
Angio Final CAU run32
In this case, we were able to identify the calcified nodule along with the ulcerated plaque and severe calcified plaque by IVUS, therefore we decided to perform rotational atherecotomy. After stent deployment, IVUS images showed good stent expansion and no malapposition.