CASE20220825_003
RCA with Anomalous LCX Bifurcation Stenting
By , , ,
0
Presenter
Suresh Yerra
Authors
1, 1, 1, 1
Affiliation
, India1
Imaging - Physiologic Lesion Assessment
RCA with Anomalous LCX Bifurcation Stenting
1, 1, 1, 1
, India1
Clinical Information
Patient initials or Identifier Number
45 YEAR LADY MRS.MS
Relevant Clinical History and Physical Exam
45 YEAR LADY WITH NO PRIOR COMORBIDITIES PRESENTED WITH NEW ONSET EXERTIONAL ANGINA SINCE 2 WEEKS. SHE UNDERWENT CAG ELSEWHERE, WE REVIEWED HER CAG-CD WHICH SHOWED ANOMALOUS LCX ARISING FROM DOMINANT RCA WITH TIGHT OSTIAL STENOSIS IN RCA AND LCX. SHE CAME TO US FOR FURTHER MANAGEMENT. ON EXAMINATION HER VITALS AND CVS EXAMINATION WAS NORMAL. HER ECG AND ECHOCARDIOGRAPHY WAS UNREMARKABLE.
CAG.mov
CAG.movRelevant Test Results Prior to Catheterization
THE ISSUES WE HAD WAS TO KNOW IF LCX HAS A SEPERATE ORIGIN OR IS IT COMING FROM RCA WITH A SHORT COMMON TRUNK. IF SEPARATE ORIGIN, THEN OUR PLAN TO TO HAVE A V STENTING, OR ELSE BIFURCATION STENTING (MEDINA 1,1,1). WE HAD THE OPTION OF IVUS VS CT-CAG WE CHOOS CT-CAG AS IT GIVES PRIOR INFORMATION AND AID IN UPFRONT PROCEDURAL PLANNING AND ALSO GIVES CLARITY ABOUT AORTA AND OTHER MAJOR VESSELS OF ARCH TO RULE OUT TAKAYASU ARTERITIS. CT CAG SHOWED SHORT COMMON TRUNK 2-3 MM.
Relevant Catheterization Findings
SO BIFURCATION STRATEGY WAS PROVISIONAL STENTING WITH RESCUE TAP. ISSUE WE HAD WAS NOT ENOUGH LENGTH FOR POT. RCA WAS ENGAGED WITH AR1 7F GUIDING CATHETER.
GUIDE.mov
GUIDE.movInterventional Management
Procedural Step
RCA AND ANOMALOUS LCX WERE SECURED WITH BMW WIRES AND RCA LESION PREDILATED WITH 2 X 12 AND 2.5 X 12 NC BALLOONS. OSTEO-PROXIMAL RCA STENTED WITH 3.5 X 15 MM DES. RCA STENT OPTIMIZED WITH 4 X 8 MM NC BALLOON. NOW THE ISSUE WE HAD WAS TO DEFINE LCX OSTIUM, WE HAD THE OPTION OF IVUS VS FFR, WE CHOOSE FFR AS IT GIVES FUNCTIONAL SIGNIFICANCE OF THE LESION. BASELINE FFR WAS 0.83 AFTER NTG AND IT WAS STRONGLY POSITIVE POST ADENOSINE (0.64). SO KISSING BALLOON INFLATION (KBI) WAS DONE WITH 3.5 x 12 MM NC IN RCA AND 2.5 X 12 MM NC IN LCX. POST KBI FFR WAS NEGATIVE POST ADENOSINE (0.92) WITH NO RESIDUAL EDGE DISSECTION OR COMPROMISED FLOW. FINAL RESULT WAS TIMI III FLOW IN RCA AND LCX.
WIRE.mov
PREDILATION.mov
POST PREDIL.mov
STENT.mov
POST DILATION.mov
FFR.mov
KBI.mov
FINAL.mov
WIRE.mov PREDILATION.mov POST PREDIL.mov STENT.mov POST DILATION.mov FFR.mov KBI.mov FINAL.movCase Summary
IMAGING HELPS IN PRIOR PLANNING IN SUCH COMPLEX CASES, CT-CAG IN OUR CASE HELPED IN PLANNING THE BIFURCATION PCI. PHYSIOLOGICAL EVALUATION HELPS IN DECISION MAKING ABOUT SB TREATMENT IN BIFURCATION LESIONS.