Author + information
- Shih-Hung Chan1
Patient initials or identifier number
Relevant clinical history and physical exam
A 62 year-old male with hypertension and hyperlipidemia presented with crescendo angina pectoris. Treadmill exercise test revealed positive result for myocardial ischemia. Renal function and left ventricular systolic performance are normal. Physical examination did not reveal remarkable abnormal finding.
Relevant test results prior to catheterization
Treadmill exercise test: positive for myocardial ischemia
Echocardiography: Adequate LV systolic performance with LVEF 64%
Multi-slice coronary CTA:
1. The calcium score is 89.0
2. LM-3VD showing multifocal plaques and stenosis with
a) 50-69% stenosis at distal LM
b) Near 90% stenosis at dLCX
c) >70% stenosis at mRCA, dRCA, pLAD, D1 branch and pLCX
d) 50-69% stenosis at pRCA, mLAD and OM branch
Relevant catheterization findings
LM:70% stenosis at dLM
LAD:70% stenosis at pLAD; 90% stenosis atD1
LCX:90% stenosis at LCX orifice, 99% stenosis at dLCX, 70% stenosis at OM1
1. A 7Fr JL4 GC was used. The LAD, LCX,and OM2 were wired.
KBT with a balloon(1.25/10) in OM2 and a balloon(3.5/15) indLCX was done.
2. Wired OM1. A balloon (2.5/15) was usedto dilate OM1
A Resolute Integrity stent (2.5/18) was deployed at OM1
A balloon(3.5/15) was used to crush the OM1 stent
Rewired the OM1. The balloon (1.25/10) was used to open OM1 stent KBT with a balloon (3.5/15) in LCX and a balloon (2.5/15) was done
3. A Resolute Integrity stent (3.5/38) deployed at LCX
A balloon(3.5/15) was used to crush LM-LCX stent. Rewiredthe LCX
A balloon(2.5/15) was used to open the LM-LCX stent
A NC balloon(3.5/12)was used to dilate LM-LCX stent
KBT with a NC balloon(3.5/12) in LM-LCX and a balloon(3.5/15)in LM-LAD was done
4. A Resolute Integrity stent(3.5/22) was deployed at LM-pLAD.
A balloon (2.5/15) used to dilate D1
A Resolute Integrity stent(2.5/26) was deployed at D1
A balloon (3.0/20) used to crush LAD-D1 stent
KBT with a balloon (3.0/20) in LAD and a NC balloon(2.5/10) in D1 was done.
A Resolute Integrity stent (3.0/26) deployed at LAD.
Rewired the D1
KBT with a NC balloon (3.25/15) in LAD and a NC balloon (2.5/10) in D1 was done
A NC balloon (3.5/12) was used to dilate pLAD
5. Rewired the LCX. KBT with a NC balloon (3.5/10)in LM-LCX and a NC balloon (3.5/12) in LM-LAD was done.
Rewired the OM1. KBTwith a NC balloon (3.5/10) in pLCX and a NC balloon (2.5/10) in OM1 was done
A NCballoon(4.0/8) was used to dilate LM
In order to completely, treat the bifurcation lesions in LM/LAD/LCX, LCX/OM1, LCX/OM2, and LAD/D1 bifurcation, we chose double kissing crush two-stent technique for LM/LAD/LCX, LCX/OM1, and LAD/D1 bifurcation. Unlike the standard procedure in traditional double kissing crush technique, we performed two-stage double kissing balloon angioplasty because of the complex triple bifurcation lesion in our patient. Using our modified methods, we can finish the complex lesions without difficulty.