Author + information
- Tomohiro Yamasaki1
Patient initials or identifier number
Relevant clinical history and physical exam
A 68 year-old male was carried to our hospital with sudden onset chest pain. The CAG revealed occlusion of the mid portion of RCA and a severe stenosis of the LAD. PrimaryPCI was performed to RCA lesion. However, he remained exertional chest oppression. Then we performed PCI to LAD lesion.
Relevant test results prior to catheterization
Relevant catheterization findings
The left CAGshowed significant stenosis of the proximal and mid portion of LAD.
A7 French EBU 3.5 guide catheter was engaged to the LCA. IVUS showed an eccentricfibro-fatty plaque in the proximal part of LAD, and a diagonal branch-1 (D1)arose from intra-plaque, while a diagonal branch-2 (D2) arose fromcontralateral plaque. Kissing balloon technique was done at the LAD lesion and D1.And a DES was deployed at the LAD lesion. However, the left CAG showed that D2flow was delayed (Figure 2).
Several 0.014 inch floppy wires were not able to cross D2 over the stent strut. Then a 0.014 inch moderate stiff wire was attempted to advance, it was entered sub-intimal space of D2. Therefore, to perform IVUS guided PCI. A 0.014 inch floppy wire dared to enter sub-intimal space and the IVUS catheter was delivered on the wire. As a second wire, a 0.009 inch Conquest Pro wire with a micro-catheter was advanced beside the first wire. The IVUS was placed at the transitional site of true lumen and sub-intimal space. The second wire advanced into the direction of the beneath of the IVUS catheter at LAO 13 degree and Cranial 40 degree on the cine angiogram image where the IVUScatheter was coincided with the first wire (Figure 3).
The second wire was certainly inserted into the true lumen confirmed by the IVUS. Then two DESs were deployed from D2 to the proximal part of LAD. Kissing balloon performed and proximal optimization technique was done at the proximal LAD.Final angiogram showed that the procedure was successful (Figure 4).
If we encounter the coronary ostial large dissection, IVUS guided GW control maybe helpful for wire crossing to the small true lumen. To catch the true lumen,confirm the positions of GW and IVUS catheter, and then rotate GW suitable degrees. IVUS plays an indispensable role in the treatment of complex lesions, and may be helpful in keeping “true lumen tracking”.