LAD Osteal ISR ve IM Osteal Stenosis: Complex PCI in Tetrafication

Operators:Doç. Dr. Mutlu Vural

Bağcılar Education and Research Hospital

Case Summary

The 52 yerar-old male patient who underwent LAD osteal PCI one year ago was admitted to the hospital due to the resting angina. When angiography is performed at admittance, the patient suffers VF before puncturing, which was successfully defibrillated. An angiography is performed after the defibrillation. According to the council result, complex PCI decision was planned and processed.

Preliminary Assessment and Strategy

A short proximal lesion of RCA was evaluated as insignificant (Video 1). There are plaques in LM proximal and distal. LAD osteal stent was found to be inadequate expansion with osteal critical instent restenosis (superposition due to high diagonal in tetrafication). The IM stenosis was the culprit lesion. Stenosis just few milimeters from the ostium of the IM is regarded as osteal lesion.

In this patient, starting with 8F left guide catheter and three guidewires, neglecting the high diagonal, provisional operation of the LCX, implantation of DES into the IM as LM to IM crossover after dilataion of the stent stratum and predilatation of IM stenosis. It would be followed by LAD stent optimization and final kissing with NC balloons.


The patient has plaques proximal and distal to LM. The 8F left guide catheter was inserted and three guide wires sent to the LAD, IM and LCX through it (Video 2). Predilatation was performed at 12 atm with 2.5×15 compliant balloon, which also dilated stent strats ( Image 1). Then the position 3.0×28 mm DES was adjusted from LM to IM (Video 3) and inflated at 16 and 20 ATMs ( Image 2). It was seen that the proximal stent was not well opposed (Video 4). On top of this, the LMCA-IM stent was optimized with a 3.0×9 NC balloon. The wire in the LCX was sent to the LAD and the jailed wire in the LAD was removed. Then, an anchor of IM balloon could make easy to introduce a 3.0×20 mm NC balloon in to the LAD ( Image 3). Previous stent was optimized up to 25 ATMs. Then, once the LCX balloon was opened alone in the ostium, final kissing was performed twice at 12 ATMs, so that the kissing balloons covered the proximal stent within the LM ( Image 4). Thin high-diagonal arterial flow was observed to be TIMI-1 but the patient was comfortable (Video 5). Medical treatment for ostium stenosis of small caliber LCX was considered due to the fact that the LCX has also distal stenosis and TIMI-3 flow. The process was terminated because the result was satisfactory (Video 6).

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Video 6

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