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Relevant Clinical History and Physical Exam
A 66 year-old gentleman was admitted with effort related angina for 3 months. His coronary risk factors were hypertension, hyperlipidemia, and ex-smoker. The physical examination was unremarkable. The ECG and cardiac enzymes were normal.
Relevant Test Results Prior to Catheterization
Thallium SPECT showed hypoperfusion 90% LCx territory with partial reperfusion at rest image.
The echocardiography showed normal LV systolic function (EF=76%) without regional wall motion abnormality.
Relevant Catheterization Findings
1. Left coronary angiogram showed Medina 1, 1, 1 lesion at distal LM bifurcation and another Medina 1, 1, 1 lesion over LCX-OM bifurcation. Also, M/3-LAD showed severe calcified segmental stenosis.
2. The right coronary angiogram showed atherosclerosis change over M/3-RCA.
1. A 6 Fr EBU 3.5 guiding catheter was engaged
2. We performed Culotte technique with two Biomatrix DES at LCX-OM bifurcation (pic1).
3. The m-LAD lesion was then pre-dilated with NC balloon several times. We not only cannot dilate m-LAD completely (pic2), but also caused a long dissection flap over m-LAD (pic3). So, we gave up to treat m-LAD lesion, and left it along for staged PC
4.We then performed Culotte technique with two Biomatrix DESs at LAD-LCX bifurcation (pic4) and closed 1st PCI.
5. 35 days later, we performed staged PCI for m-LAD (pic5). Sheathless procedure was done using VTK diagnostic catheter loaded in 7Fr EBU catheter.
6. Debulking atherectomy was performed at m-LAD using a 2.0 burr (pic6).
7. After atherectomy, we fully pre-dilated m-LAD (pic7) and used IVUS for proper stent sizing. A BVS was placed at m-LAD and another BVS was deployed at p-LAD according to patient’s personal stent preferences (pic8).
8. Two years later, effort-related angina re-occurred. Given the severity of his symptoms, he was admitted for 3rd coronary angiogram. The angiography and OCT showed in-stent stenosis in previous Culotte DES stenting at ostium-LCX and m-LCX (pic9).
9. We also found previous BVSs were partial resolved and the vessel size became positive remodeling. An aneurysm formation over 3.0 * 28 mm BVS and 3.5 * 28 mm BVS junction (pic10).
10. We performed balloon angioplasty with a Dior DEB at m-LCX and another Dior DEB at p-LCX. Final angiography showed excellent outcome.
According to previous clinical trials, patients who received BVS placement had a higher incidence of late/very late scaffold thrombosis rate compared with DES. However, in our patient with complex lesions, the implantation of BVS appeared better than DES. BVS is feasible in complex lesions, such as heavy calcification and un-dilatable lesions only if completely well lesion preparation, using imaging guide for BVS sizing and post-dilatation. PSP implantation strategy is the key of success which may reduce future MACE post BVS stenting and contribute to well results.