Author + information
- Debasis Mitra1
Patient initials or identifier number
Relevant clinical history and physical exam
A 68 years old gentlemen, heavy smoker (20 Cigarette/day) and past history of COPD presented with recurrent history of chest pain for > 18 Hours. He had Hyperlipidemia. Echo showed No regional wall motion abnormality and Ejection fraction was 60%. Blood pressure was 140/80 mmHg, pulse 84 beats / Min regular and body weight of 72 kg. BMI 24. On clinical examination chest was clear, a heart sound was normal with no sign of murmur.
Relevant test results prior to catheterization
ECG : Normal Sinus Rhythm
Echo showed Ejection fraction-60 %. No regional wall motion abnormality. Normal cavity sizes.
Hb : 12.8 gm/dl
creatinine : 1.1 mg/dl
Cholesterol : 290 mg/dl
LDL: 180 mg/dl
HDL: 32 mg/dl
Triglyceride: 192 mg/dl
FBS : 128 mg/dl
Relevant catheterization findings
LMCA : Normal
RCA : Dominant & Normal
LCx : Non Dominant but totally occluded just from the origin
LAD : Angiography showed significant flow limiting disease in Diagonal and LAD & Ramus Intermedius. IVUS done in LAD & D1 and found LAD lesion is not significant. Angiographically look like 0:1:1. But after IVUS it was 0:0:1. Accordingly diagonal predilated and stented with DES using backstop technique.
Guide Cath EBU 7F used. Direct stenting to Ramus Intermedius was done with DES 2.25 x 28 mm at 12 ATM. Post Dilation was done with 2.5 x 10 mm NC balloon at 14 ATM.
Wiring was done in both LAD and D1 with floppy wire. Intravascular Ultrasound Atlantis SR Pro 3.5F (Boston Scientific, 40 Mhz) was done in LAD and D1 pre-procedure. IVUS in D1 showed significant concentric fibrofatty plaque and IVUS in LAD showed plaque burden < 50% and CSA > 5.00 mm2.
A 3 x 15 mm balloon was kept in LAD. Then the D1 lesion was pre dilated with Pantera Leo 2.5 x 12 mm at 12 ATM and DES 2.75 x 15 mm deployed in D1 with backstop technique at 10 atm. The balloon deflated and taken out. Post dilatation done with 3 x 10 mm NC balloon. Subsequent scene showed TIMI III flow with no residual stenosis in Diagonal stent.
Routine Intravascular Ultrasound guided bifurcation stenting is helpful to access the vessel size, diameter, and plaque burden. In this case, IVUS helped us to determine and confirm the flow limiting lesion i.e. diagonal only. Angiographically LAD looked significant but IVUS ruled it out.
Medina 0:0:1 is always difficult to stent and to ensure that ostium cannot not be missed. Single stent strategy for treating bifurcation is always better for both in acute as well as a longterm result. Backstop technique ensures the proper coverage of the side branch without any geographical mismatch.