Currently, left main (LM) stenting is considered a IIB indication per the American College of Cardiology/American Heart Association Guidelines1, with surgery still considered the preferred method of revascularization for LM disease. However, improvement in interventional techniques, drug-eluting stents (DES) and pharmacotherapy have resulted in increased frequency of LM percutaneous coronary intervention (PCI). Current data in the DES era has demonstrated promising results with short-term follow up (< 5 years) in patients undergoing LM PCI with regards to mortality, although target vessel revascularization (TVR) remains higher with PCI.2 Currently, LM PCI is primarily performed in patients who are not considered good surgical candidates or refuse bypass.
This particular patient was not considered a good surgical candidate because of his diminished pulmonary capacity, as well as concerns about his ability to rehab after bypass.
History of Present Illness. A 69-year-old male with a past medical history of gastroesophageal reflux disease, hypertension, and chronic obstructive pulmonary disease was seen in the emergency room (ER) with complaints of chest pain that had been going on for several days. The pain has been constant, left-sided in location, and not associated with nausea or vomiting. He was evaluated in the ER and admitted to the hospital. At this point, his second and third set of troponins came back positive. He had no prior artery coronary disease.
Procedure. The patients’s left radial artery was prepped and draped in a sterile fashion. The left radial artery was accessed with a 6 French Terumo Glidesheath (Somerset, New Jersey). We upsized to a 7 French sheath and used a Q 3.5 guide to engage the left main. Bivalirudin (Angiomax, The Medicines Company, Parsippany, New Jersey) was administered. A Runthrough wire (Terumo) was then advanced into the ramus. A Balance wire (Abbott Vascular, Redwood City, Calif.) was advanced into the left anterior descending coronary artery (LAD). We then took an 0.9 excimer laser and with a setting of 80/80, made 2 passes in the ostium of the LAD and then 2 passes in the ostium of the ramus. The patient did have calcification, and because of the inability to protect the side branch with a RotaWire (Boston Scientific, Natick, Mass.), we chose to use laser atherectomy instead of rotational atherectomy. Following this, we took a 3.0 x 10 mm AngioSculpt balloon (AngioScore, Inc., Fremont, Calif.), predilated the LAD at 10 atm, and then went over the Runthrough wire and predilated the ramus at 10 atm. On both occasions, the balloon fully expanded, with angiographic improvement of the lesions. We then took a 3.0 x 18 Promus stent (Boston Scientific) into the LAD and a 3.0 x 18 into the ramus, bringing them back into the left main to create a carina. We then went simultaneously up on both of them at 12 atm, deflated, then individually at 16 atm, and then again simultaneously at 12 atm.
At this point, we took a 3.5 x 12 mm Quantum (Boston Scientific) into the LAD and a 3.5 x 12 mm Quantum into the Promus and postdilated the proximal portions of the stents in a simultaneous manner, initially individually at 16 atm and then simultaneously at 12 atm. We then administered intracoronary nitroglycerin. Angiography revealed brisk flow with a good angiographic result. We took the intravascular ultrasound (IVUS) catheter into the LAD and into the ramus, and demonstrated that the stents were well apposed, without any evidence of edge dissection, and appropriately sizing the left main, which was approximately 5.5 mm.
The wires were removed and orthogonal views were obtained, revealing TIMI-3 flow in the LAD and the ramus. There was some plaque shift in the ostium of the native circumflex artery, which essentially supplies a small posterior left ventricular artery (PLV). We did not attempt to treat the plaque shift because of the small caliber of the vessel, and there was still good flow into the PLV.
The patient tolerated the procedure well. The guide was removed and a TR Band (Terumo) was placed over the radial artery.
The patient’s procedure was done on a weekday morning, and he was dischaged the following afternoon (length of stay 2 days). He was sent home on clopidogrel, beta blockers and baby aspirin, and is currently doing well.
Orlando Marrero can be contacted at firstname.lastname@example.org
- Kushner FG, Hand M, Smith Jr. SC, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 and 2007 focused update): a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2009;54:2205–2241.
- Park DW, Seung KB, Kim YH, et al. Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol 2010 Jul 6;56(2):117–124.
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