Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
This 52 year-old man is a patient of: (1) Hypertension (2) Mitral valve prolapse with trivial mitral regurgitation H suffered from intermittent chest tightness shortness of breath when he climbed stairs or walk to fast for 6 months ago. Chest tightness with dyspnea for recent 3 months occurred frequently. The symptoms exacerbated with heavy exercise and partially relieved after rest.
1. Cigarette smoking: 1PPD for 20 years; quit for 7 years
Relevant test results prior to catheterization
The calcium score in LM, LAD, LCX and RCA were measured 599.55, 127.31, 74.65 and 447.68, respectively; total calcium score was 1249.19, which indicated a presence of extensive atherosclerotic plaques in the coronary arteries.
Relevant catheterization findings
CAG via right radial artery showed left main with triple vessel disease(distal left main: 70% stenosis with bifurcation lesion, medina (1, 1, 1).
Leftanterior descending artery: Ostium to middle part: Diffuse lesion, up to 80%stenosis with calcification; left circumflex artery: Ostium to middle part:Diffuse lesion, up to 90% stenosis, distal part: 70% stenosis; right coronaryartery: Proximal to distal part: Diffuse lesion, up to 70% stenosis at middleportion) LVEF: 56%
The right femoral approach was done with one FL4/7 GC engaging LMCA. LAD-M and LCX-D lesion treated first. For LM true bifurcation lesion, two stent strategy with culotte technique planned. One run through hypercoat GW advanced to LAD-D and another Sion GW advanced to LCX-D. Sequential pre-dilatation with one Trek 3.0 x 20 mm BC at LCX-D to LM and 2.5 x 20 mm in LAD-D to Os, up to 12 atm. KBT was done with pressure up to 6 atm.
Due to sub optimal result,one Resolute Integrity 3.5 x 26 mm DES was deployed at LCX-D, up to 12 atm. Due to post POBA dissection type B, one Resolute Integrity 3.0 x 18 mm was deployed at LAD-P to M, up to 9 atm. Due to the ostial lesion, one Resolute Integrity 4.0 x 26 mm DES was deployed at LM to LCX-P, up to 9 atm. Due to difficult wiring, LAD was re-wired by one Sion Blue GW under the support of one Ikazuchi 2.5 x 15 mm BC.Then the 2.5 mm BC was inflated at LM to LAD-M instent, up to 14 atm. Due to LAD-Oslesion, one Resolute integrity 4.0 x 22 mm DES was deployed at LM to LAD-P, up to 16 atm. Final KBT was done with NC quantum 4.0 x 15 mm BC over LM to LCX-P up to 8 Barr,NC quantum 3.5 x 15 mm BC over LM to LAD-P up to 8 atm.
We followed this patient in 2 years later and coronary angiogram showed no instent restenosis.
Several observational studies had shown that the provisional one-stent approach for distal LM was associated with more favorable outcomes, including lower risks of major adverse cardiac events, death, myocardial infarction, lower risk of stent thrombosis and target vessel revascularization. However, two-stent with culotte technique considered for significant ostial stenosis of the LCX with a dominant left coronary arterial system.