PCI in Left Main Coronary Bifurcation Disease

-Step Mini Crush

TianJin Chest Hospital

Wei Wang Hantao Jiang

Feng XX Male 55Y Chief Complaint ： Intermittent Chest Pain for 5 years ， aggravate 3 days 。

Risks factors : Hypertension for 5years ， smoking for 20y and quit smoking10y 。 Intermittent Alcohol intake 。

Case Information

PE ： HR 56 bpm ， BP 160/90mmHg

UCG ： LA32mm LV54mm LVEF 62%

Decreased diastolic function

LAB ： TG 5.19 TC 1.88

HDL 0.97 LDL 3.45

Case Information

75%Stenosis in LMd , 70%-80% stenosis inLADpm, 70% stenosis in LCXp SYNTAX SCORE 28

CAG

IVUS

MLD 2.03mm

MLA 4.41mm2

PB 77% IN LM

MLD 1.78mm MLA 2.93mm2 PB 72% inLADPull back from LAD

IVUS

MLD1.76mm MLA3.64mm2PB 65% in LCX

PCI Equipment

Procedure Approach ： TFA 7F sheath

Guiding Catheter ： 6F EBU3.75

Guide wires ： LAD– Runthrough

LCX– Whispher

Baloon Catheter ： 2.5*20mm(Sprinter-Legend)

2.0*15mm(Sprinter-Legend)

3.0*12mm(NC Sprinter)

4.5*8mm(NC Voyager)

Stent ： LM--4.0*23mm(Firebird2)

LAD--3.0*29mm(Firebird2)

LCX—3.0*13mm(Firebird2)

PCI

3.0*29mm Firebird2 Stent deployment in LADp to middle ,after predilatation in LADm and LMd

PCI

predilatation in LCXp and LADp, 3.0*13mmFirebird2 stent deployment in LCXp to LMd

PCI

Inflate the baloon in LM, and crush the stent protruded into LM from LCXp

accurate position of ostial LM stent

PCI

4.0*23mm Firebird2 stent deployed from LADm to the ostium of LM

PCI

Rewire LCX ， post dilate LADp to ostial LM and LCXp with 4.5*8mm and 3.0*12mm NC baloon separately ， final kisssing

PCI

IVUS to check stent apposition from LADm to LM

IVUS

Check stent apposition from LCX to LM

IVUS

COMMENT distal LMCA bifurcation Medina

1,1,1 SYNTAX SCORE 28 CABG or PCI

PCI One or Two Stents

IVUS Pre OR Post

CAD subset CABG favored

PCI favored

1- or 2-vessel disease, nonproximal LAD IIb C I C

1- or 2-vessel disease, proximal LAD I A IIa B

3-vessel disease, simple lesions, full revascularization achievable with PCI, SYNTAX score <22

I A IIa B

3-vessel disease, complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22

I A III A

Left main (isolated or 1-vessel disease ostium/shaft) I A IIa B

Left main (isolated or 1-vessel disease distal bifurcation) I A IIb B

Left main plus 2- or 3-vessel disease, SYNTAX score <32 I A IIb B

Left main plus 2- or 3-vessel disease, SYNTAX score >33 I A III B

Indications for CABG vs PCI in patients suitable for both procedures

Chinese Journal Cardiology,April 2012,Vol. 40 No. 4

LAD=left anterior descending coronary artery

IVUS: LM stenting Always IVUSPRE FOR intermediate lesions FOR Sizing and procedural planning To assess ostial LAD and LCX To determine when(and howmuch)to debulkingPOST IVUS Criteria for optimal stent expansion -LMCA MSA ≥8.5mm -LADo or p MSA ≥6.5mm -LCXo or p MSA ≥5.5mm(≥4.0mm if not stented) -no plaque burden ＞ 50% at a stent edge and no

major edge dissection.If either are present ,stent it!Acute malapposition is not importmant :Don’t chase it! BIGGER IS BETTER------even with DES

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