Case 7: Proximal LAD stent underexpansion and malapposition
Case Presentation
A 55-year-old male came to the outpatient clinic because he had recently become aware of chest and shoulder pain associated with exertion. He had a history of multiple PCI procedures, hypertension, dyslipidemia, hyperthyroidism, and IDDM. Echocardiography showed reduced left ventricular wall motion, with ejection fraction of 42%. SPECT showed ischemia in the inferior wall.
Angio Pre
Coronary angiography revealed a hazy area in the proximal LAD, and when IVUS was performed, malapposition of the stent was observed. Visualized in the image below, the IVUS catheter was found to have crossed the stent through a strut after the proximal edge due to this malapposition. Therefore, the wire was reinserted. Repeat IVUS showed that the wire was no longer entering through a stent strut and a 4.0mm non-compliant balloon was dilated up to 18 atm pressure.
IVUS First Pullback
IVUS After rewiring now within stent
In this case, by confirming the lesion with IVUS, it was found that the wire had passed through a stent strut. Review of the pullback allowed us to reinsert the wire into the stent before balloon dilatation. Thus, if malapposition is present at the proximal edge of the stent, it is possible that the wire has passed through the stent strut and special precaution should be taken to avoid stent deformation.
