Intravascular Ultrasound Images as an Essential Tool to Assist Left Main Operating Strategy

ABSTRACT: Intravascular ultrasound (IVUS) remains the only tool to understand, plan and evaluate complex lesions in percutaneous coronary intervention (PCI). Despite the evidence for left main intervention,¹ it is routinely used mainly to validate the final results in terms of optimal expansion of the stent.^1,2 In this case report, we wish to highlight the role of IVUS guidance in the decision-making process throughout the PCI procedure.

J INVASIVE CARDIOL 2010;22:E177–E178

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Intravascular ultrasound (IVUS) remains the only tool to understand and evaluate complex lesions, allowing better planning of percutaneous coronary procedures. For left main interventions it is routinely used to validate the final result in terms of optimal stent expansion and apposition.^1,2 In this case, we wish to highlight the role of IVUS guidance in the decision-making process throughout the procedure. Case Report. A 74-year-old male was admitted to our hospital for unstable angina, with angina at rest for the past week. He had suffered a previous inferior myocardial infarction, and in 1998 underwent coronary artery bypass surgery, with grafting of the left internal mammary artery to the left anterior descending artery (LAD) and two saphenous vein grafts to the posterior descending artery for an occluded right coronary artery and grafting to the second marginal branch of the circumflex (CX). The actual coronary angiogram showed a very calcified, critical left main (LM) lesion extending to the bifurcation involving mainly the origin of the LAD. The LAD was occluded after the septal and first diagonal branches. The CX still had a well-developed third obtuse marginal branch (Figure 1). Despite the patient’s normal left ventricular function, the surgeon refused to reintervene because all the grafts were permeable and functional. The importance of the patient’s symptoms compelled us to propose intervention on the LM artery. Due to the Y shape of the bifurcation, we decided to perform “culotte” stenting. The preparation of the lesion used rotational atherectomy, due to the level of calcification, with a 1.75 burr directed towards the LAD, followed by a kissing balloon dilatation of the bifurcation. Then, a 3.0 drug-eluting stent 30 mm Endeavor Sprint stent (Medtronic Inc., Minneapolis, Minnesota) was implanted from the ostium of the LM to the proximal LAD, at 14 bars. This maneuver moderately affected the CX ostium. IVUS was used at each step to evaluate the lesion modifications. After easy rewiring and kissing-balloon dilatation of the bifurcation, IVUS revealed that the CX wire was in fact beside the LM stent, and not inside it (Figure 2A); none of the angiograms showed this in posteriori review (Figure 2B). After overexpansion of the LM stent portion with a 4.0 mm balloon, we easily achieved correct wire position in the CX, as confirmed by a new IVUS run. A second 3.0 x 18 mm Endeavor Sprint was finally implanted using the culotte technique. Our intervention was then completed as it was originally planned, avoiding an involuntary crushing of the first stent (Figures 3 A and B). Conclusion. Seeing is understanding...and believing. IVUS guidance seems to be more than a complement to angiography when treating complex lesions. Relevant information, not always detectable by angiography, may tailor the treatment strategy, thereby avoiding complications.

References

1. Gerber R, Colombo A. Does IVUS guidance of coronary interventions affect outcome? Catheter Cardiovasc Interv 2008;71:646–654. 2. Orford JL, Lerman A, Holmes DR. Routine intravascular ultrasound guidance of percutaneous coronary intervention: A critical reappraisal. J Am Coll Cardiol 2004;43:1335–1342.

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From Giovanni Di Dio e Ruggi D’Aragona University Hospital, Salerno, Italy. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 15, 2010, and accepted February 8, 2010. Address for correspondence: Tiziana Attisano, MD, Giovanni Di Dio e Ruggi D’Aragona University Hospital, S. Leonardo Street, Salerno, Italy. E-mail: attiziana@tiscali.it