Ultra Low Contrast Unprotected Left Main

Percutaneous Coronary Intervention Using Intravascular Ultrasound

And Sepal Technique

Kristy Brillantes Garganera, MD1

Bryan Rene F. Toledano, MD1

Jose Paolo A. Prado, MD2, Michelangelo L. Sabas, MD2

1. Fellow In Training – Interventional Cardiology

2. Consultant – Interventional Cardiology

Cardiovascular Institute, The Medical City, Philippines

Disclosure

• All authors do not have financial interest or affiliations with one or more organizations that could be perceived as conflict of interest in context of this presentation

Clinical History and Physical Examination

• 60 year old male, hypertensive, diabetic, CKD stage 4

• Presenting with easy fatigability

• Managed as a case of Ischemic Cardiomyopathy and referred to this institution for coronary intervention

• At the ER: BP 110/70 mmHg, HR 71 bpm regular rhythm,

Respiratory rate 20 cpm not in distress

• Pink palpebral conjunctivae, non engorged neck veins, clear breath sounds, apex beat at the 5th intercostal space mid axillary line with no murmur on auscultation. There was note of grade 1 bipedal edema.

Pre-Procedural Tests

• Chest Xray AP view showed no significant chest findings

• Serum creatinine 251.40 umol/L, eGFR 23

• Uric acid 565.90 umol/L

• HbA1c 9.3

• ECG 12 leads showed sinus

bradycardia with poor R wave

progression

Coronary Angiography

BA C

Radial Access, 5F DxTerity catheter

LAD: 90-95% proximal to mid stenosis with myocardial bridging

Coronary Angiography

BA C

LM: 65% stenosis

LCx: 30-40% mid and 20% distal stenosis

RCA: 70-80% distal segment stenosis

Pre-Intervention IVUS of the LAD to LMCA

2.08 mm2

3.85 mm2

Boston Scientific 3.0F OptiCross 40 MHz

PCI of the Left Anterior Descending Artery

1 2

3 4

Guide: 7F EBU 3.5

Guidewire: Asahi Sion Blue

Predilation: Emerge 2.50 x 15 mm

Synergy 3.0 x 38 mm Synergy 4.0 x 38 mm

Longitudinal stent deformation of Ostial stent struts

POT: NC Quantum Apex 5.0

A B

C D

Post PCI IVUS RUN of the Left Anterior Descending Artery to LMCA

Post PCI Angiography

Discussion Points

• Cost-effective method of Aorto-Ostial LM stenting done with the aid of a sepal technique

• Previous angiography shots used as roadmaps for wire placement, and IVUS in replacement for contrast injection proved useful and effective as alternative for PCI in patients with high risk for CIN

Conclusion

• With proper planning, IVUS-optimized ultra low contrast PCI of unprotected LM with crossover stenting to LAD is feasible and can be safely done especially in patients who are at high risk for having contrast induced nephropathy.

• IVUS was vital for assessment of vessel diameter, plaque morphology, adequacy of lesion preparation, stent sizing and length, and apposition of stent struts to vessel wall.

• Coronary wires were used as visual guides as to where we positioned our balloons and stents coupled with IVUS and strategies such as the sepal wire technique for aorto-ostial LMCA stenting to avoid geographic miss.