Author + information
- Mohd Kamal Mohd Arshad1,
- Hafisyatul Aiza Zainal Abidin1,
- Effarezan Abdul Rahman1,
- Rizmy Najme Khir1,
- Johan Rizwal Ismail1,
- Nicholas Yul Chye Chua1,
- Khairul Shafiq Ibrahim1,
- Chiao Wen Lim1,
- Zubin Ibrahim1 and
- Sazzli Kasim1
Patient initials or identifier number
Relevant clinical history and physical exam
A 59 year old man presented with chest pain and shortness of breath on exertion.
He has a past medical history of ischaemic heart disease 2 years ago with an abnormal stress test at stage III that was treated medically. He also has type 2 diabetes mellitus and dyslipidaemia. Clinical examination was unremarkable. Blood pressure was 140/80 mmHg.
Relevant test results prior to catheterization
ECG showed sinus rhythm with ST elevation of 0.5 mm in lead III.
Troponin T was within normal limits. Exercise stress test in this admission showed ST elevation in lead aVR at stage II with accompanying shortness of breath. Echocardiography showed normal ejection fraction of 55% with no regional wall motion abnormalities. The valves were normal.
Relevant catheterization findings
Coronary angiogram showed an 80% bifurcating lesion in the mid left anterior descending artery/2nd diagonal with diffuse distal disease (Medina 1.0.1). The 2nd diagonal has a 50% ostial lesion extending 5 mm into the proximal segment. The rest of the coronaries showed non-obstructive atheroma.
We opted for a provisional stenting strategy via the right radial artery. The left main was engaged with a Backup Left 3.5 6F guide. A Sion Blue wire was wired down the left anterior descending (LAD) to distality and a BMW wire was wired down the 2nd diagonal. Intravascular ultrasound (IVUS) assessment of mid LAD using Boston Opticross (Boston Scientific, Massachusetts, USA) showed a distal reference lumen diameter of 3.8 mm and a proximal reference diameter of 4.15 mm. A 3.5 x 15 mm compliant balloon was used to predilate the lesion at 12 atm.
The LAD lesion was stented across the 2nd diagonal with a Magmaris (Biotronik AG, Buelach, Switzerland) 3.5 x 20 mm bioresorbable scaffold (BRS) deployed at 12 atm for 20 seconds. It was then post-dilated with a 4.0 x 15 mm non-compliant balloon to 18 atm distally and 20 atm proximally. IVUS assessment post procedure showed a well-apposed scaffold without edge dissection. The ostium of the 2nd diagonal is not compromised as confirmed angiographically and on IVUS. The mean stent diameter at distal scaffold was 3.38 mm and proximal scaffold was 3.88 mm despite high-pressure post dilatation with a 4.0 mm NC balloon. Final angiography showed good TIMI 3 flow in both the LAD and the 2nd diagonal.
The advantages of a BRS are the reduction of complications such as stent fracture, late stent thrombosis and in-stent restenosis with the postulated return of vasomotor function and the resulting late lumen gain. The magnesium scaffold BRS is a sirolimus coated drug eluting absorbable magnesium scaffold. Despite the strut thickness of 150 nm and the presence of 2nd diagonal disease, the 2nd diagonal remained patent after BRS deployment and remained so after post dilatation. This is a first reported case of a Magmaris BRS in a bifurcation lesion. We demonstrated the successful use of a Magmaris BRS across a main vessel of a Medina 1.0.1 bifurcation lesion with preservation of the side branch.