Complex Case: LM and LCX
The patient is a 66-year-old female with a past medical history of hypertension, hyperlipidemia, anemia, obesity, and CAD with CABG in 1999 (LIMA to LAD). She presented with intermittent exertional chest pain. Diagnostic cardiac catheterization demonstrated LM distal 80%, LAD proximal 100% with a patent LIMA/LAD, LCX proximal 80% stenosis, and RCA ostial 50% stenosis. A nuclear stress test demonstrated a small- to medium-sized area of inferior ischemia and LVEF of 67%. She underwent PCI of the LM and LCX lesions using a 3.5 EBU guide catheter. A wire was advanced toward the diagonal branch, and rotational atherectomy with a 1.5 mm burr was performed in the left main. This was followed by wiring of the LCX; however, LCX lesion crossing with a balloon was unsuccessful, and the procedure was aborted due to concerns regarding the risk of local complications (Figs. 11.1 and 11.2 and Videos 11.1 and 11.2). The patient was referred for an additional PCI attempt. A BMW wire was used to cross the lesion facilitated with a Finecross micro-catheter. The micro-catheter did not cross the LCX lesion; however, a floppy Rota wire was advanced alongside the BMW wire successfully. The BMW wire was then removed. Rotational atherectomy using a 1.25 mm burr at a speed of 170–180 k was performed followed by a second run with a 1.5 mm burr. Pre-dilatation was performed with a 2.5 × 12 mm noncompliant balloon, followed by successful PCI of the proximal circumflex with a 3.25 × 12 mm drug-eluting stent, and successful PCI of the LM with 3.5 × 23 mm DES overlapping the LCX stent (Figs. 11.3 and 11.4 and Videos 11.3 and 11.4). Excellent angiographic results with TIMI III flow were noted. IVUS imaging confirmed optimal apposition and expansion of the treated lesion.
Baseline LCX lesion. A highly calcified lesion is appreciated in the proximal LCX (MP4 346 kb) (MP4 346 kb)
A wire was advanced toward the diagonal branch and rotational atherectomy with a 1.5 mm burr was performed (MP4 261 kb) (MP4 261 kb)
Rotational atherectomy with a 1.25 mm burr followed by a 1.5 mm burr was performed on the LCX lesion leading to post-atherectomy lumen size gain and allowing stent crossing (MP4 1431 kb) (MP4 1431 kb)
Final result: Optimal stent deployment was validated with IVUS guidance (MP4 1424 kb) (MP4 1424 kb)