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Percutaneous Stenting for Unprotected Left Main Chronic Total Occlusion
J INVASIVE CARDIOL 2017;29(10):E147-E148.
Key words: chronic stable angina, chronic total occlusion, percutaneous stenting
A 62-year-old, male, hypertensive non-smoker was admitted with history of chronic stable angina for the past 2 years. He underwent coronary angiography 6 months earlier, which showed ostial occlusion (Figure 1A; Video 1A) of the left main coronary artery (LMCA) with 70% lesion in the dominant right coronary artery (RCA) (Figure 1B; Video 1B). The left anterior descending (LAD) and left circumflex (LCX) arteries were filling through collaterals from the RCA (Figures 1C, 1D; Videos 1C, 1D). The patient was advised to undergo coronary artery bypass graft (CABG) surgery; however, he refused. Six months later, the patient was readmitted with worsening angina (Canadian Cardiovascular Society class III). His resting electrocardiogram was normal. Transthoracic echocardiography was normal. The patient refused to undergo bypass surgery, but consented to the non-surgical alternative of percutaneous coronary intervention (PCI) with stenting. Repeat coronary angiography showed ostial occlusion of the LMCA (Figure 2A; Video 2A) with critical stenosis in the mid RCA (Figure 2B; Video 2B). The collaterals to the left coronary artery from RCA were faintly visualized. It was decided to first perform PCI of the LMCA chronic total occlusion followed by PCI of the RCA, because the RCA was the single surviving artery with TIMI III antegrade flow supplying the entire heart and any complication while performing RCA could result in cardiac arrest. There was severe angina with hypotension while performing RCA injection; thus, contralateral injection while performing PCI of the LMCA was avoided.
The stump of the LMCA was engaged with a 7 Fr Extra Backup 3.5 guiding catheter (Medtronic). The lesion was then crossed with a 0.014˝ Pilot-150 hydrophilic wire (Abbott Vascular), and the wire was advanced into the LAD (Figure 2C; Video 2C). The lesion was dilated with 1.5 x 10 mm Sprinter balloon catheter (Medtronic) at 12 atm. After inflation, some antegrade flow was restored in the LMCA to the LAD. The LCX could also be faintly visualized. The lesion was serially dilated with 2.5 x 12 mm and 3 x 12 mm Sprinter balloons to achieve antegrade flow (Figure 2D; Video 2D). The LMCA lesion was stented with a 4 x 28 mm Xience Prime stent (Abbott Vascular) from its ostium to the proximal LAD at a pressure of 12 atm (Figure 2E; Video 2E). The stent was postdilated with a 4.5 x 12 mm Sprinter NC balloon at 24 atm. Later, the RCA lesion was stented with a 3.5 x 18 mm Xience Prime (Abbott Vascular) (Figure 2F; Video 2F). There was no complication and the patient was discharged after 48 hours. He was asymptomatic at a clinical follow-up after 8 months, and exercise stress test was negative.
Chronic total occlusion of the LMCA is rare. Conventionally, CABG has been considered the treatment of choice in patients with disease in the LMCA. However in carefully selected patients with favorable anatomy, PCI can be considered a safe alternative.
