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Successful Management of gChronic Total Occlusion of Left Anterior Descending Artery andAnterior Descending Artery and
Diagonal Bifurcation Using Intravascular Ultrasound and
Parallel wire techniqueParallel wire technique
Presenter : Ji Young ParkOperator : Jae Woong Choi, Sung Kee Ryu
Institution: Eulji General Hospital, Seoul, Korea
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Clinical History and PhysicalClinical History and Physical Examination
• 65-year-old male with effort chest pain for 12 months.
• Risk factor: ex- smoker, 15 pack year smoking historysmoking history
• ECG : T wave inversion in V1,2,3,4• Echo : EF 65%, no RWMA
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Baseline CAG
A long calcified se ere stenotic lesion in the pro imal LAD (T pe C) TIMI 1 floA long calcified severe stenotic lesion in the proximal LAD (Type C), TIMI 1 flow
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Severe stenotic lesion ofSevere stenotic lesion of
1st diagonal branch
(Type B2 lesion).
Medina classification
(1,1,1)
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The well developed collateral branches were shown from distal RCAshown from distal RCA to distal LAD (grade 2) . Therefore, we assumed th t i l LAD l i ithat proximal LAD leision seems to be progressing
chronic total occlusion due to well developed collateral branches.
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PCI at Bifurcation p-LAD & 1st Dx
6Fr. JL4 Guiding catheter
was engaged through
Rt femoral approachRt. femoral approach.
Prox. LAD with Fielder XT,
1st diagonal branch with gBMW
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• However, wiring of LAD was failed due to , g1) Insufficient wiring control space2) Very severe acute angle) y g
• Side branch dilatation
Very acute angle
Insufficient space
•Widening space of wiring
Insufficient spaceIVUS
guided wiringwiring
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Wi h d tWire was changed to Fielder FC, and
sequential predilatationsequential predilatation was done in ostium of
LAD using voygerLAD using voyger 1.5x15mm and
2.0x15mm.
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PCI t i l LADPCI at proximal LAD
with Conquest .
After wiring, patient complainedcomplained
1) severe chest pain
2) SBP < 80mmHg) g
3) HR>100 / minute
Intraarterial balloon pump (IABP)
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Strategy of Escape from ‘ False lumen’
• Parallel or seesaw wire technique
• IVUS guided wiring• IVUS-guided wiring
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IVUS guide parallel wire technique
Parallel wire technique was performed using Conquest and MiracleConquest and Miracle
wires in LAD
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IVUSIVUS
Ist Dx
Tip of Wire inWire in
LAD
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IVUS : True lumenIVUS : True lumen proximal distal
Tip of Wi i distalWire in
LAD
1st Dx
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LAD PCI
Voyger 2x15 mm,
Two Xience 2.75 x18 mm at proximal and mid LAD
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Final angiographyFinal angiography
showedshowed successfully
revascularization ofrevascularization of LAD with TIMI 3
grade flow. g
The patients did not complained of pchest pain, and systolic blood pressure was
increased 120mmHg.
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Final angiographyg g p y
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ConclusionConclusionWe learned through this caseWe learned through this case • In bifurcation lesion with main branch CTO,
predilatation at side branch can make the wiring space widening.wiring space widening.
• However, in this process, unexpected i i LAD d h d icompromising LAD made hemodynamic
status unstable and leaded to chest pain.
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ConclusionConclusion
I l t CTO t b f• Incomplete CTO seems to be far more dangerous lesion than we guess and very careful managements are needed.
• IVUS guided wiring technique is helpful• IVUS guided wiring technique is helpful technique to advance in a true lumen during CTO inter entionCTO intervention.