1. A Case of LM , Bifurcation, CTO PCI and…Complications
Jingyu Hang
Shanghai Jiaotong University
Sixth Hospital
CIT 2010
BEIJING

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

3. 1st PCI LM CTO Recanalization UR UR UR

4. LM Chronic Occlusion

5. LM PCI
Guidewire: Conquest Pro 9
Taxus Liberte 4.0*12mm

6. Wire Dissection 2nd Stent
Flaws of 1st procedure:
1.LM proper views (cranial vs. caudal); IVUS always if available
2.LAD-LM bif. Multiple views are required before finish off the case
Wire dissection in LAD
Taxus Liberte 3.5*20mm

7. 1 Month Later Chest Pain again!!!
ECG (-)
Cardiac biomarkers (-)
Left main stent occlusion?
Diagonal Compromise?

8. Ostial Diagonal Stenosis --Carina Shift by Stent?
Stent jailed: carina shift rather than true diseased ostium.
KBT will suffice. Just to correct carina shift
If want another stent, choose a longer one. Short stent is very hard to position. In this particular case, causes stent loss.
Always read angiograms carefully and thoroughly before finish off.

9. 2nd PCI “Reverse Crush” in Diagonal

10. Diagonal Stent Positioning
Taxus Liberte 3.0*8mm
without Pre-dilatation

11. Diagonal Stenting --Reverse Crush

12. Balloon Crush and KBT

13. Happy with Final Result?

14. 2 Months Later Chest Pain again!!!
Left main restenosis?
Diagonal ostium restenosis?
Stent thrombosis?

15. 3rd PCI

16. LM Re-occlusion; How come stent is here?

17. 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.

18. Aortic Cusp Dissection

19. 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
Incidence of stent embolization 1.2%
Systematic and intracoronary embolization.
The first goal is to safely bring the embolized material to the iliac artery.
A limitation of balloon-assisted stent retrieval is the inadvertent retraction of the guidewire.
2 wires outside guiding catheter are bound together by a torque device which is rotated clockwise about times, until the wires are observed twisting together near the proximal end of stent.

20. Confirm Wire in Stent

21. Balloon Dilatation and Stent Retrieval

22. IVUS LAD-LM Stent Crushed
Vision4*28mm
Vision 4.0*28mm
4-5 layers of metal in LAD

23. Final Result Diagonal was left untouched

24. Lessons Learned Complications in a Single Patient Complex PCI
Stent dislodgment
Wire dissection
Aortic cusp dissection
Complex PCI
LM Stenting： Proper angio views don’t miss ostium
IVUS guided
Re-intervene : don’t go underneath
Bifurcation： Jailed large SB –KBT will suffice
Reverse crush –Predilation is mandatory
CTO: Wire handling

25. Hopefully she won’t come back again… Thank you!