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Three Vessel PCI Versus Bypass Surgery Reduced to One Vessel PCI by Smart Use of HD-IVUS and Catheter Based FFR

Paul S. Teirstein, MD., F.A.C.C.
Chief of Cardiology, Scripps Clinic
Director, Interventional Cardiology, Scripps Clinic
Director, Scripps Prebys Cardiovascular Institute, Scripps Health

After considering bypass surgery for three vessel disease involving an unprotected left main, this patient was sent to the cathlab for stenting of the LAD and Circumflex ostium, possible stenting of the mid-LAD, with additional stenting of the RCA. Catheter based FFR assessment of the total coronary tree narrowed the treatment plan to stenting of the mid-LAD only, because the other lesions were not functionally significant. The value of FFR pullback is demonstrated when pullback in the LAD found the lesion in the mid-LAD to be flow limiting, rather than the ostial lesion. The importance of high definition intravascular ultrasound in selecting the appropriate stent landing zone and stent length is also demonstrated. This case emphasizes that the angiogram can be deceiving when used for selecting stent position and length. HD IVUS also helped identify stent malapposition and underexpansion.

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