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
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
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.