Percutaneous Coronary Intervention-1summitmd.com/pdf/pdf/3_Sugaya.pdf · Percutaneous Coronary Intervention f L ft M i A t M di l I f tifor Left Main Acute Myocardial Infarction;

Percutaneous Coronary Intervention f L ft M i A t M di l I f tifor Left Main Acute Myocardial Infarction;

Stay calm, and things will go well.

Teppei Sugaya

Cardiovascular CenterHokkaido Social Insurance Hospital

Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital

Case: Male in his 70’s

• Clinical history: yThe patient presented with severe chest pain

and dyspnea for 1 hour.

• Coronary risk factor: Current smoking HypertensionCurrent smoking, Hypertension

• Blood pressure at emergency room : p g y100/70 mmHg

• Breath sound : Clear


ECG: Sinus rhythm, HR 70, ST segment elevation in aVr T wave progression in V1 2ST-segment elevation in aVr, T-wave progression in V1-2ST-segment depression in Ⅱ, Ⅲ, and aVF, V3-6


Approach siteApproach site

For CAG and PCI Possible Left Main ACS

Rt Femoral arteryLt F l t7 Fr sheath

for Guiding catheterLt Femoral artery

5 Fr sheath

In order to exchange to cannula for PCPS immediately if required

Rt Femoral vein7 Fr sheathfor temporary pace maker Lt Femoral vein

immediately if required.


for temporary pace maker Lt Femoral vein5 Fr sheath

Baseline Coronary Angiography (LCA)


Blood pressure 80 / 40 mmHg

Left main ACSLeft main ACS• The incidence of acute LMCA occlusion is 0.9% in

ti t ith STEMI d i i i l tpatients with STEMI undergoing primary angioplasty.

D it f f i PCI ti t ith AMIJACC cardiovasc intv 2011 Jun;4(6):618-26.

• Despite performance of primary PCI, patients with AMI due to LMCA occlusion were associated with >50% in-hospital mortalityhospital mortality.

Point.Catheter cardiovasc intv 2012 Jan 10.

Point.

Don’t hesitate to start PCPS(percutaneousDon t hesitate to start PCPS(percutaneous cardiopulmonary support) in acute left main ACS if not contraindicated.Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital

ACS if not contraindicated.

Approach sitepp

For primary angioplasty For PCPS

Rt Femoral arteryRt Femoral artery7 Fr sheath

for Guinding catheter

Rt Femoral artery16 Fr Cannulafor PCPS

Rt Femoral vein7 Fr sheathfor Temporally pace maker

Rt Femoral vein21 Fr Cannulafor PCPS


for Temporally pace maker

Baseline Coronary Angiography (RCA)with PCPS

Intratracheal intubation with sedation.

BP: 100 / 70 mmHg

PCPS flPCPS flow: 2.0-2.6 L/min1900-2100 RPM

ECG: sinus rhythm, HR 70


AspirationAspiration

G/C: 7Fr Judkins Left G/W: Sion blue


G/C: 7Fr Judkins Left G/W: Sion blue

After aspirationAfter aspiration

Suspicious of true bifurcation lesion; MEDINA classification (1 1 1)


Suspicious of true bifurcation lesion; MEDINA classification (1,1,1)

LCX wiring micro catheter(Finecross) + Fielder FCmicro catheter(Finecross) + Fielder FC

Crossing of guide wire was very difficult due to stenosis of


LCX ostium and extremely angulated bifurcation.

Multifunctional catheterMultifunctional catheterCrusade

Superior GW movementA “Double layer lumen” allows superior GW movement.


LCX wiring with Crusade + Fielder FCg

We reacted calmly this difficult situation because of


ypatient’s stable condition with PCPS.

Comparison of wire movement

Without Crusade With Crusade


Kissing balloon


LAD: 2.5x15 mm LCX: 2.5x15 mm

After kissing balloonAfter kissing balloon


IVUS


Modified T (mini crush) stenting

LCX: 3.5x23mm EES Crush balloon: 3.0x20mm

Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance HospitalLAD: 3.5x23mm EES

Wire recross to LCXWire recross to LCX

Thereafter wire recross into LCX was attempt with Fielder FC alone.


IVUS to LADLCX

distal

Wire

proximal

The wire re-crossed into


the proximal strut.

Gap

The two stents are actually in a crossed position.(One above the other)

PointRecrossing the wire to the distal strut is favorable in crush stenting.

Proximal strutProximal strut

Distal strut

Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance HospitalCollapse of the strut into side branch

LCX wiring with Crusadeg

Crusade can also prevent the wire from crossing out of the gproximal edge of stent if struts are malaposed.

The wire was successfully recrossed to the distal strut with Crusade, and we reacted


calmly this complication task because of the patient’s stable condition with PCPS

IVUS to LADIVUS to LADdistal

LCX

WireWire

proximal

The wire situated on the distal side


the distal side

Final Kissing Balloon TechniqueFinal Kissing Balloon Technique


LAD: 3.5x20 mm LCX: 3.0x20 mm

IVUS


Final AngiographyFinal Angiography


LVGLVG


After PCIFor IABPFor IABPand Central vein catheter

For PCPS

Rt Femoral artery

Central vein catheter

Rt Femoral arteryRt Femoral artery y16 Fr Cannulafor PCPS

Rt Femoral artery7 Fr sheathfor Guinding catheter

Rt Femoral artery8 Fr sheathfor IABP

Rt Femoral veinfor central vein catheter

Rt Femoral vein21 Fr Cannulafor PCPS

Rt Femoral vein7 Fr sheathfor temporary pace maker


Clinical courseClinical course• Peak CK 9800 U/L• 1 POD weaning from PCPS• 1 POD weaning from PCPS• 4 POD weaning from IABP• 6 POD weaning from ventilator• 6 POD weaning from ventilator• 8 POD reintubation due to pulmonary edema

9 POD pericardial drainage• 9 POD pericardial drainage• 14 POD left thoracic drainage

18 POD i ht th i d i• 18 POD right thoracic drainage• 19 POD weaning from ventilator

21 POD it CCU• 21 POD exit CCU• 37 POD CAG : no restenosis of stents

ODivision of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital

• 42 POD discharge home

3-month follow up CAG3 month follow up CAG


12-month follow up CAG12 month follow up CAG


SummarySummary• We experienced and successfully treated a

case of left main AMI with complicated bifurcation lesion.

• We reacted calmly in this tough case duringWe reacted calmly in this tough case during PCI procedure because of the patient’s stable condition with PCPS.condition with PCPS.

C d i f l th t f t l• Crusade is a very useful catheter for extremely angulated bifurcation and recrossing after crush t tiDivision of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital

stenting.

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Percutaneous Coronary Intervention-1summitmd.com/pdf/pdf/3_Sugaya.pdf · Percutaneous Coronary Intervention f L ft M i A t M di l I f tifor Left Main Acute Myocardial Infarction;