Figure 4.1
Baseline angiographic images, black ovals, showing representative LAD and ramus stenosis. (a) and (b) taken in right anterior oblique views, (c) and (d) taken in left anterior oblique views
Figure 4.2
Black arrow showing chronic total occlusion of RCA
The left main coronary artery was engaged with a vista XB3.5 7 Fr guiding catheter. A 0.014″ guidewire was placed beyond the lesion in the ramus. The lesion was predilated with an AngioSculpt 2.5 × 10 mm balloon with ultimate stenting with a DES 2.75 × 18 mm stent post-dilated to 2.75 mm (Fig. 4.3).
Figure 4.3
Scoring balloon atherectomy (right) followed by eventual stenting with 2.75 × 18 mm DES
The 0.014″ guidewire was then directed down the LAD and exchanged for a 0.009” Rota extra-support wire. Rotational atherectomy was performed using a 1.25 mm burr at 150,000 rpm for multiple passes (Fig. 4.4) with repeat angiography showing improved but persistent calcific disease (Fig. 4.5). The burr was replaced with a 1.50 mm burr, and rotational atherectomy was again performed with the upsized burr at 150,000 rpm for 60 s for multiple passes (Fig. 4.6). The Rota wire was then exchanged for a standard 0.014″ guidewire. The LAD lesion was further treated with an AngioSculpt 2.5 × 10 mm and 3.0 × 15 mm balloon. Ultimately a 4.0 × 38 mm DES was deployed across the LAD lesion. The stent was post-dilated with a noncompliant quantum apex 4.0 × 20 mm balloon (Fig. 4.7). Subsequent angiography revealed that the diagonal vessel had been jailed (Fig. 4.8) with a new ostial stenosis (“pinched”) secondary to plaque shifting. We next advanced an additional 0.014″ guidewire through the LAD stent struts and into the diagonal artery (Fig. 4.9). Both the diagonal branch and the LAD stent were post-dilated in a simultaneous kissing balloon (Fig. 4.10) with subsequent angiography demonstrating a well-apposed stent and TIMI 3 blood flow and a residual diagonal stenosis of 30%. Final angiography revealed excellent angiographic results (Fig. 4.11).
