A Case of LM ,Bifurcation, CTO PCI and…Complications

Jingyu Hang

Shanghai Jiaotong UniversitySixth Hospital

CIT 2010

BEIJING

History

52yr Female Chest pain on exertion 6 month ECG (-) Troponin (-), CKMB (-) RF: HTN Echo: Moderate Aortic regurg.

Preserved LV function.

1st PCI LM CTO Recanalization

2009-1-15

LM Chronic Occlusion

LM PCI

Guidewire: Conquest Pro 9

Taxus Liberte 4.0*12mm

Wire Dissection 2nd Stent

Taxus Liberte 3.5*20mmWire dissection in LAD

1 Month Later Chest Pain again!!!

ECG (-) Cardiac biomarkers (-)

Left main stent occlusion? Diagonal Compromise?

Ostial Diagonal Stenosis --Carina Shift by Stent?

2nd PCI “Reverse Crush” in Diagonal

2009-3-3

Diagonal Stent Positioning

Taxus Liberte 3.0*8mm

without Pre-dilatation

Diagonal Stenting --Reverse Crush

Balloon Crush and KBT

Happy with Final Result?

2 Months Later Chest Pain again!!!

Left main restenosis? Diagonal ostium restenosis? Stent thrombosis?

3rd PCI

2009-4-30

LM Re-occlusion; How come stent is here?

Why Stent Dislodged in This Case?

SB wire crossed smaller cell.

Direct stenting with stent cell not enlarged by pre-dilatation.

Stent dislodged before enter SB.

Embolized during re-wiring.

Aortic Cusp Dissection

How to Handle Stent Loss?

No Tx for peripherally embolized stent

Deploy stent at unimportant location

Remove with 2 twisted wires Remove by inflating a small balloon Remove by snare/forceps/basket Crush the stent by stent

Confirm Wire in Stent

Balloon Dilatation and Stent Retrieval

IVUS LAD-LM Stent Crushed

Vision 4.0*28mm

4-5 layers of metal in LAD

Final Result Diagonal was left untouched

Lessons LearnedComplications in a Single PatientStent dislodgment Wire dissectionAortic cusp dissection

Complex PCILM Stenting ： Proper angio views don’t miss

ostium IVUS guided Re-intervene : don’t go underneathBifurcation ： Jailed large SB –KBT will suffice Reverse crush –Predilation is

mandatoryCTO: Wire handling

Hopefully she won’t come back again…

Thank you!Thank you!