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Provisional Stent with Difficulty of Side Branch Reaccess 边支再进入困难的“即兴”支架术

Provisional Stent with Difficulty of Side Branch Reaccess 边支再进入困难的“即兴”支架术. LIU Tongku, Ding Fuxiang The Center of Cardiology, Affiliated Hospital , Beihua University Jilin 132011, Jilin, China 北华大学附属医院心脏中心 刘同库 , 丁福祥.

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Provisional Stent with Difficulty of Side Branch Reaccess 边支再进入困难的“即兴”支架术

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  1. Provisional Stent with Difficulty of Side Branch Reaccess边支再进入困难的“即兴”支架术 LIU Tongku, Ding Fuxiang The Center of Cardiology, Affiliated Hospital , Beihua University Jilin 132011, Jilin, China 北华大学附属医院心脏中心 刘同库, 丁福祥

  2. Provisional Stent with Difficulty of Side Branch Reaccess边支再进入困难的“即兴”支架术 Provisional Stent with Difficulty of Side Branch Reaccess refers to the phenomenon that is when the bifurcation lesions is treated by provisional stenting technique, the ostial of side branch is squeezed from lesion plaques shift to make the side branch ostial stenosis , occlusion or stent beam cover ostial of side branch, and subsequently to make reaccess difficulty of wire, balloon or stent. We report a case of provisionalstent with difficulty of side branch reaccess. please discuss it. 临时支架置入技术(Provisional stenting technique)即“即兴”支架技术 边支再进入困难的“即兴”支架术,是指分叉病变，采用provisional stenting 技术，边支开口受到病变斑块移位挤压，使边支开口高度狭窄或闭塞或支架挠骨梁覆盖狭窄的边支口，使后续的导丝、球囊或支架再进入困难或不能进入的现象 ！ 我们报告一例边支再进入导丝困难的病例，请指点

  3. Case Presentation(1) Clinical presentation (Medical record No. 201219041) A 46 year-old male was admitted due to intermittent chest pain for one year, which was aggravated in last one week. Indoor walking can induce the chest stuffy pain before one week. He was admitted to our hospital on 16th November,2012. When he did heavy physical activity ,typical angina pectoris occurred in nearly 1 year, which can relieve by rest or administering isosorbide dinitrate. Medical history (previous history) Before one year he suffered from AMI (inferior wall and posterior wall myocardial infarction ) to admit other hospital and to do not PCI. After discharged from hospital he have been taking aspirin, clopidogrel, atorvastatin, and so on, and still had onset of chest pain. Risk factor only smoking for 30 years(20 / day). 患者，男，46岁（病例号：201231407）因间断发生劳力性胸痛1年，加重1周，于2012 年11月16日入院。近1年每于重体力活动时发生胸痛呈典型心绞痛发作，休息或含服消心痛可以缓解。入院前1周症状加重，室内散步可以诱发心绞痛。 既往病史：于1年前患AMI（下后壁）住外院治疗好转，未行介入诊治。出院后口服“阿司匹林、氯吡格雷、阿托伐他汀”等药物治疗，仍间断有胸痛发作. 吸烟史20年，20支/天。否认高血压、糖尿病病史。

  4. Case Presentation(2) Physical Examination T 36.2℃,P 62/min, BP:120/80mmHg（millimeter of mercury). The heart rate was 60 per minute. Cardiac auscultation showed that heart sounds was normal, and each valve area was without murmurs. The tiny bubbles sounds were heard in double lungs low . His liver was not big and lower limbs no swelling. T 36.2℃, P 62/min, BP:120/80mmHg 口唇无发绀，无颈静脉怒张，双肺呼吸音清，未闻及干湿罗音。心界叩诊不大，心率60次/分，心音低钝，节律规整，各瓣膜听诊区未闻及杂音、额外心音及心包摩擦音。双肺低有少许水泡音。肝脏不大，双下肢无水肿。

  5. The patient’s electrocardiograph was abnormal. R-waves were lower in Ⅲ and aVF. ST segments and T-waves were not abnormal. The heart rate was 60 per minute.

  6. Blood examination WBC: 3.3×10^9/L MEUT:50.0% RBC: 4.31×10^12 HGB: 125g/L PLT: 172×10^9

  7. Blood Lipid and myocardial enzymes Chol 3.7 mmol/L TG 2.8mmol/L LDL 2.19 mmol/L HDL 0.77mmol/L CK-MB 7.06u/L CK 55.0u/L a-HBDH 146.0u/L AST 20u/L cTnI 0.01ng/L Glu 4.9mmol/L

  8. Echocardiography (ultrasonic cardiogram .UCG) LA 34mm AO 31mm LV 45mm IVS 6.6mm LVPW 6.6mm RVOT 26mm RV 26mm EF 0.65

  9. Baseline coronary angiogram Her coronary angiogram was completed on 16th November, 2012. Coronary angiogram showed that LCX was CTO lesions and RCA 3 segment was 90% stenosis ,and without collateral flow to LCX distal vessel. CTO lesion Stenosis lesions

  10. Baseline CAGHer coronary angiogram was completed on 16th November, 2012. RAO 30°CAG LCX-CTO

  11. Baseline CAG CAU 25°LCX-CTO with collateral circulation

  12. Baseline coronary angiogram LAO40°CAG showed there was stenosis in RCA 3 segment

  13. CRA 25°CAG showed there was stenosis in RCA 3 segment

  14. diagnosis • Coronary heart disease • Unstable angina pectoris • Old inferior and posterior wall myocardial infarction • Double branch lesions of coronary artery (LCX-CTO and RCA stenosis) • Heart function 1 class

  15. Procedure of PCI（1） First, A 6 Fr BL 3.5 guiding catheter was inserted in ostium of LM via radial artery. We used Whisper guide wire into LCX. But Whisper wire cannot access the lesion.

  16. Procedure of PCI（2） Then we tried to use a small balloon (1.5×15 mm) to support the wire into lesions . CAG showed the wire was in true lumen of blood vessel .

  17. we Procedure of PCI（3） We used Whisper guide wire into LCX distal and used small balloom (1.5×15) to dilate the lesions. Then we inserte BMW wire into distal OM3.

  18. Procedure of PCI（4） We used Whisper guide wire into LCX distal and used small balloom to dilate the lesions. Then we inserte BMW wire into distal OM3.

  19. Procedure of PCI（5） After the dilatation with small balloon CAGshowed bifurcation lesions of LCX. We used provisional stenting.

  20. Procedure of PCI（6） We used 2.0×20 mm balloon to dilate it.

  21. Procedure of PCI（7） Stent (Xience V 2.75×18mm) was inserted into the LCX lesions

  22. Procedure of PCI（8） Stent was inflated with 14atm×15” (XIENCE V)

  23. Procedure of PCI（9） Post-dilation with 3.0×12 mm balloon and with 16atm×15”

  24. Procedure of PCI（10） The CAG after the post-dilatation showed severe stenosis of OM 1 ostium

  25. Procedure of PCI（11） Difficulty of Side Branch Reaccess. The wire was operated for 10min.The wire cannot be inserted into OM1, to give up it.

  26. Procedure of PCI（12） Difficulty of Side Branch Reaccess. The CAG after withdrawn from wire

  27. Procedure of PCI（13） To operate for 10 min, to give up. This is final result of LCX

  28. Procedure of PCI（14） RCA bifurcation lesion was treated with Culotte stenting Double BMW wire were used. PD ostium lesion was dilated with 2.0×20mm balloon 12atm×15”.

  29. Procedure of PCI（15） In RCA 3-PL 2.75×24mm partner was implanted with 14atm × 15”

  30. Procedure of PCI（16） In RCA3-PL 3.0×18mm stent was implanted with 14atm×15”

  31. Procedure of PCI（17） This was final kissing balloon with 10atm×10”

  32. Procedure of PCI（18） The final result of RCA Culotte stenting

  33. Discuss • What is the cause of trouble of side branch reaccess？ • What is the prevention method of difficulty of side branch reaccess? 1、Provisional stenting 后，导丝再进入边支困难的原因? 2、预防导丝再进入边支困难的方法?

  34. Thank you for your attention 报 告 者: 刘同库；E-Mail:liutongku20102163.com;电话：18943209667 单 位: 北华大学附属医院心脏中心 通信地址：吉林市解放中路12号，北华大学附属医院心脏中心

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