|Year : 2020 | Volume
| Issue : 1 | Page : 71-74
Problem of complete ostial coverage in short left main artery
Himanshu Gupta, Dinakar Bootla
Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||13-Dec-2019|
|Date of Decision||21-Jan-2020|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||17-Apr-2020|
Department of Cardiology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh
Source of Support: None, Conflict of Interest: None
A 58-year-old male presented with unstable angina and strongly positive myocardial perfusion imaging. Coronary angiogram revealed significant left main (LM) and multivessel disease. He underwent LM and bifurcation percutaneous intervention by provisional side-branch strategy after heart team discussion. After LM to proximal left anterior descending stenting, left circumflex wire was recrossed followed by kissing balloon inflation (KBI). Stent boost after KBI showed fractured stent in the LM artery. Why did this complication occur and how did we manage is described in detail in this case report.
Keywords: Abnormal course of coronary wire, case report, complex coronary intervention, left main bifurcation, stent boost
|How to cite this article:|
Gupta H, Bootla D. Problem of complete ostial coverage in short left main artery. J Pract Cardiovasc Sci 2020;6:71-4
| Introduction|| |
Left main (LM) bifurcation percutaneous intervention (PCI) has many challenges and is a high-risk PCI. This case highlights the specific problems when stent covers the ostium of LM, especially in patients with a short length of the LM vessel.
| Case Report|| |
A 58-year-old male, with risk factors of hypertension and smoking, presented with unstable angina for the past 14 days. On evaluation, electrocardiogram and resting echocardiogram were normal, but stress myocardial perfusion imaging showed large reversible perfusion defects in anterior and inferolateral territories. He was taken up for coronary angiogram, which showed left dominant circulation with diffuse LM disease (Medina 1, 1, 0), about 70% diffuse severe disease in proximal and mid-left anterior descending (LAD), 90% disease in distal left circumflex (LCx) disease with SYNTAX score of 31 [Figure 1]a, [Figure 1]b, [Figure 1]c and Videos 1, 2]. He was taken up for angioplasty following heart team discussion because of long waiting times for coronary artery bypass grafting (CABG) and good results of LM interventions by percutaneous approach in our institute, also the patient was unwilling for CABG. PCI was done with drug-eluting stent to distal LCx, mid LAD and LM to LAD with Synergy® 2.75 mm × 28 mm, Xience Prime® 3 mm × 38 mm, respectively. LM ostium to proximal LAD was then stented with Xience Prime® 3.5 mm × 33 mm [Figure 2]a, [Figure 2]b and Video 3]. After LM stenting, the first proximal optimization technique (POT) was done with 5 mm × 8 mm noncompliant (NC) balloon (according to Finet's law) to correctly oppose the stent to LM [Figure 2]c. After this, jailed LCx was recrossed with polymer-coated Fielder FC® wire for kissing balloon inflation (KBI) to open struts toward large dominant LCX artery [Figure 2]d and Video 4]. KBI was done with a 3.75 mm NC balloon in LM-LAD and 3 mm NC balloon in LM-LCx [Figure 2]e and Video 5]. Following KBI, we decided to do re-POT. After KBI, LAD wire position was lost accidentally due to balloon malfunction. Although LAD was rewired, we were not sure of the course of LAD wire, so we performed re-POT of LM stent on the re-crossed LCx wire which was earlier used for KBI [Figure 2]f and Video 6]. Stent boost images after this POT showed a significant distortion of LM stent [Figure 2]g. The differentials for this picture are longitudinal stent deformation (LSD) because of the guide catheter or crushed LM stent to one side of LM due to abnormal wire position. On careful review of previous angiograms, we recognized that re-crossed LCx wire had entered the LM through the stent struts hanging in the aorta and not from LM ostium. This problem was probably not recognized even during KBI due to polymer-coated nature of the wire and widely open-cell spaces after the first POT which resulted in no resistance to balloon passage. After this, we were left with a crushed stent in LM ostium partially hanging into the aorta along with LM ostium no longer covered with a stent [Figure 3]a, [Figure 3]b, [Figure 3]c. To manage the situation, we planned to go ahead and insert a short stent Xience Prime 4 mm × 12 mm from LM ostium to mid-LM so that we cover the diseased part of LM and also have no additional stent across the LCX artery. The stent Xience Prime® 4 mm × 12 mm was deployed with significant protrusion into the aorta [Figure 4]a, and the final POT was done with 5 mm × 12 mm NC balloon. After stenting, we used guide extension catheter to selectively engage the LM to prevent LSD by the guiding catheter and take final angiograms. The final angiogram showed adequate lesion coverage and thrombolysis in myocardial infarction 3 flow in all the vessels [Figure 4]b and Video 7]. Final stentboost showed good apposition of stent in the LM and confirmed previously damaged stent struts which were now hanging in the aorta and covered LM ostium with a new stent [Figure 4]c. The postprocedural course was uneventful, and he was discharged a day later on double antiplatelet (prasugrel and aspirin) and high-dose statin. He was asymptomatic during follow-up, and check angiogram after 9 months showed excellent angiographic result [Figure 5]a and b and Video 8].
|Figure 1: Diagnostic angiographic images (a) Spider view showing short left main with diffuse severe disease (orange arrow) (note: Left main caliber smaller than left circumflex). (b) Right anterior oblique cranial view showing significant mid and proximal left anterior descending diffuse disease (orange arrows) (c) Left anterior oblique cranial view showing distal left circumflex (dominant vessel) with significant disease (orange arrow) and mid left anterior descending significant disease (blue arrow).|
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|Figure 2: Left main - left anterior descending and left circumflex bifurcation percutaneous intervention (a) showing mid-left anterior descending stent, Xience Prime® 3.0 mm × 38 mm with proximal and distal edges in angiographically healthy areas (orange arrows) (b) From ostial left main to mid-left anterior descending Xience Prime® 3.5 mm × 33 mm (orange arrows) with adequate coverage of the left main ostium (c) First proximal optimization technique in left main with 5 mm × 8 mm noncompliant balloon (orange arrow) before left circumflex wire recrossing (d) Recrossing left main to left circumflex (orange arrows) before first kissing balloon inflation (e) First kissing balloon inflation done with 3.75 mm noncompliant balloon in left main - left anterior descending (arrow head) and 3.0 mm noncompliant balloon in left main - left circumflex (orange arrow) (f) 5 mm × 8 mm noncompliant balloon (orange arrow) inflation was used to do the 2nd proximal optimization technique. (g) Stent boost showing left circumflex wire crossing under the deformed left main stent (orange arrow).|
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|Figure 3: Pencil drawn images to show the sequence of events (a) left main - left circumflex wire (yellow line) going under stent edges at left main entry and crossing into left circumflex, left anterior descending wire (green line). (b) Proximal optimization of left main done over abnormal left main - left circumflex wire (yellow line). (c) Deformed left main stent after proximal optimization technique over abnormal left circumflex wire with a gap at left main ostium.|
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|Figure 4: Bailout after the complication (a) left main - left anterior descending (blue arrowhead) and left main - left circumflex (orange arrowhead) were rewired and Xience Prime 4 mm × 12 mm (orange arrow) stent placed from left main ostium to neo carina over the left main to left circumflex wire. (b) Final angiogram with guide extension catheter showing the good angiographic result. (c) Stent boost showing a final image of left main and also damaged stent segment in the aorta. Can appreciate the guide extension catheter.|
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|Figure 5: Nine months follow-up angiogram (a) Anterior-posterior caudal view showing good flow across left circumflex stent (arrowhead) and ostial left circumflex with no significant stenosis, patent left anterior descending stent with no instent restenosis (orange arrows) (b) Left anterior oblique cranial view showing good flow across left main to left anterior descending stent with no in-stent restenosis.|
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| Discussion|| |
LM disease with SYNTAX scores between 23 and 32 can be managed by either CABG (Class 1) or PCI (Class 2a) with CABG being the preferred option. Medina (1, 1, 0) lesions are best treated with one stent and final KBI is optional and if KBI is done, it should be done very carefully.
This case highlights two important aspects and golden rules of complex LM interventions. First, careful rewiring of side branch during bifurcation stenting and to be sure of the position of wire before KBI. Second, never to lose the access of the main branch wire during the procedure. Both can result in devastating complications. In our case, despite a first POT to oppose the stent in LM, the wire used to re-cross into LCx passed through proximal stent struts of LM stent that were hanging in the aorta as whenever there is jailed LCX wire the guide is never coaxial, and hence, rewiring can become a problem. This was not realized immediately as there was no resistance to balloon passage for KBI probably due to wide cell opening after first POT and re-POT done on recrossed LCx wire as we had accidentally lost access to LM-LAD wire. In the absence of intravascular ultrasound or optical coherence tomography-guided rewiring, stent boost is useful in identifying the course of side branch (SB) wire to prevent these complications;, however, stent boost to confirm the wire course in relation to stent was not done in our case. At this moment, we were left with a fractured stent in LM and there was uncovered LM ostium. We went ahead with stenting the LM ostium to before LCx origin on the same LCx wire with a short Xience® 4 mm × 12 mm which covered the ostium and damaged LM struts. In this way, we corrected the gap at LM ostium due to previous stent crush and also did not have any stent layer in front of LCx ostium. Stent boost showed good apposition of the new stent on the previous one. After stenting, Guideliner® (guide extension catheter) was used to take selective angiogram and prevent LSD as guide engagement can result in significant LSD if stent struts are hanging in the aorta.
| Conclusions|| |
Complete ostial coverage in a short left main artery can lead to problems. Final kissing balloon is not mandatory in provisional Side branch stenting but if it is done utmost care should be taken. After recrossing wire, its position should be confirmed with imaging or stent boost. To avoid abluminal wiring dual lumen catheter can be used in difficult cases. Guide extension catheters are very useful to prevent longitudinal stent deformation in cases where stent is hanging into the aorta after ostial LM stenting.
Due ethical clearance taken from the institutional board.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]