Complex PCI: LAD Instent Restenosis, LM lesion and bifurcation

Operators:Doç. Dr. Mutlu Vural
Dr. Ghulam Abbas Shaikh

Bağcılar Education and Research Hospital


A 43-year-old male patient was referred to the hospital for acute anterolateral MI due to sudden fatigue and shortness of breath. He had primary PCI under a post-CPR condition after in-hospital sudden cardiac arrest. On coronary angiography, severe instent restenosis at proximal LAD was observed (Video 1A, Video 2A, Video 3A, Video 4A). The right system was normal and the septals were filled with retrogradely (Video 5A). Because of small caliber and diffusely diseased vasculature of the patient, bypass surgery was considered to be the second option. A PTCA was applied with a 2.5 × 20 balloon at 18 atm in the previous stent being diagonally oriented ( Image 1A). When the LAD flow was good after the procedure, the first treatment was terminated in preparation for options such as drug-coated balloon.


Since we delayed the appointment three times and then time passed more than two months, we did not take any further steps and the option of the drug coated balloon would be on the desk. 8F left guide catheter was introduced and a floppy wire was sent to the diagonal branch (Video 1B). The LAD was then performed in the same manner, a 2.0 × 15 for LAD and 2.0 × 20 mm balloon for a diagonal were positioned for kissing (Video 2B). After applying the PTCA separately to the LAD ( Image 1B) and then the diagonal ( Image 2B) at 16 atm, kissing was applied at 10 atm ( Image 3B). Balloons were moving distally because of proximal stent. On the other hand, because the proximal LAD was not stented an an additional DES was required due to the disease at the distal end of LM, a longer DES was preferred instead of the drug coated balloon. The wire in the diagonal was placed in the LCX (Video 3B) before stenting. LM to LAD crossover 3.0 × 24 mm DES was dilated at 18 atm ( Image 4B). Angiography showed stent was deployed 1 mm before bifurcation (Video 4B). Kissing was then carried out again at 12 atm with 2.0 × 15 and 2.0 × 20 mm balloons ( Image 5B). POT was performed with 3.5 × 12 mm balloon ( Image 6B). The process was terminated when it was satisfactory (Video 5B, Video 6B, Video 7B).

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