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

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

1st PCI LM CTO Recanalization 2009-1-15 UR 394775 UR 401457 UR 411369

LM Chronic Occlusion

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

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

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

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.

2nd PCI “Reverse Crush” in Diagonal 2009-3-3

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

Diagonal Stenting --Reverse Crush

Balloon Crush and KBT

Happy with Final Result?

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

3rd PCI 2009-4-30

LM Re-occlusion; How come stent is here?

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.

Aortic Cusp Dissection

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 15-20 times, until the wires are observed twisting together near the proximal end of stent.

Confirm Wire in Stent

Balloon Dilatation and Stent Retrieval

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

Final Result Diagonal was left untouched

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

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