Case 3: OCT Guided Complex Intervention Of LM And Long Calcified Aneurysmal LAD
Case Presentation
- A 76-year-old woman presented with angina like chest pain and dyspnea on exertion.
- Stress MPI showed lateral ischemia.
- Medical history : HTN, HLD, Gout
- Medications: Aspirin, Amlodipine, Metoprolol XL, Losartan, Atorvastatin, Allopurinol
- Coronary angiogram revealed left main disease and long calcified, aneurysmal lesion in LAD.
- Planned to undergo imaging guided complex LAD PCI.
Case Planning
OCT of LM
LM (MLA) = 4.46 mm2 (no calcium)
OCT of LAD
LAD (MLA)= 1.47 mm2 (4 quadrant calcium)
PCI Strategy
- 7F guide catheter
- With the presence of severely calcified disease, planned to use atherectomy for lesion preparation.
- Initial wire choice: Runthrough and FineCross microcatheter
- Imaging guided PCI, 2 stents vs provisional strategy
- If provisional strategy used, planned to use a jailed side branch wire (i.e. Fielder wire)1
- Pan M et al. Structural Damage of Jailed Guidewire During the Treatment of Coronary Bifurcation Lesions: A Microscopic Randomized Trial. JACC Cardiovasc Interv. 2016;9(18):1917-1924.doi:10.1016/j.jcin.2016.06.030
STEPS
- The initial choice of wire was Runthrough (180 cm) with FineCross microcatheter. Then, Rota Floppy wire will be exchanged via FineCross, followed by rotational atherectomy (1.75 Burr) of LAD.
- Fielder wire was placed in LCx along with Runthrough wire in LAD.
- One DES(Xience 3.2/38) was placed in mid LAD.
- Another DES (Xience 3.5/23) was placed from LM to LAD while jailing Fielder wire (Polymer jacketed wire) in LCx.
Runthrough and Fine Cross > ROTA Floppy Wire
Bifurcation (2 wires)
- After DES placement in LM to LAD, the ostium of LCx was jailed.
- A kissing balloon inflation was performed in LAD (3.0 compliance balloon) and LCx (3.0 compliance balloon).
- Post OCT showed stent malapposition at the aneurysm area and further optimization was done with NC balloon 4.0/8mm.
Final Angiogram
Learning Points
- In a long calcified lesion, exchanging Rotawire via FineCross is a better option than direct wiring with Rota wire.
- In Bifurcation PCI, polymer-coated wires (Fielder, Whisper MS) should be placed in jailed side branch (bifurcation stenting) as this could alleviate wire damage.1
- Imaging guided PCI is recommended in LM/LAD disease to delineate whether two stents or provisional strategy.
- To navigate through an aneurysm, the wire should have hydrophobic coated (better tactile feedback), a stiffer tip, and excellent torqueability. Runthrough was able to negotiate the lesion in this case. Other wires choice should be Gaia series and MiracleBros along with a microcatheter.
- Pan M, Ojeda S, Villanueva E, et al. Structural Damage of Jailed Guidewire During the Treatment of Coronary Bifurcation Lesions: A Microscopic Randomized Trial. JACC Cardiovasc Interv. 2016;9(18):1917-1924. doi:10.1016/j.jcin.2016.06.030
