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A Case of LM ,Bifurcation, CTO PCI and…Complications
Jingyu Hang
Shanghai Jiaotong UniversitySixth Hospital
CIT 2010
BEIJING
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History
52yr Female Chest pain on exertion 6 month ECG (-) Troponin (-), CKMB (-) RF: HTN Echo: Moderate Aortic regurg.
Preserved LV function.
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1st PCI LM CTO Recanalization
2009-1-15
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LM Chronic Occlusion
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LM PCI
Guidewire: Conquest Pro 9
Taxus Liberte 4.0*12mm
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Wire Dissection 2nd Stent
Taxus Liberte 3.5*20mmWire dissection in LAD
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1 Month Later Chest Pain again!!!
ECG (-) Cardiac biomarkers (-)
Left main stent occlusion? Diagonal Compromise?
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Ostial Diagonal Stenosis --Carina Shift by Stent?
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2nd PCI “Reverse Crush” in Diagonal
2009-3-3
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Diagonal Stent Positioning
Taxus Liberte 3.0*8mm
without Pre-dilatation
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Diagonal Stenting --Reverse Crush
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Balloon Crush and KBT
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Happy with Final Result?
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2 Months Later Chest Pain again!!!
Left main restenosis? Diagonal ostium restenosis? Stent thrombosis?
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3rd PCI
2009-4-30
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LM Re-occlusion; How come stent is here?
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Why Stent Dislodged in This Case?
SB wire crossed smaller cell.
Direct stenting with stent cell not enlarged by pre-dilatation.
Stent dislodged before enter SB.
Embolized during re-wiring.
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Aortic Cusp Dissection
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How to Handle Stent Loss?
No Tx for peripherally embolized stent
Deploy stent at unimportant location
Remove with 2 twisted wires Remove by inflating a small balloon Remove by snare/forceps/basket Crush the stent by stent
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Confirm Wire in Stent
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Balloon Dilatation and Stent Retrieval
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IVUS LAD-LM Stent Crushed
Vision 4.0*28mm
4-5 layers of metal in LAD
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Final Result Diagonal was left untouched
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Lessons LearnedComplications in a Single PatientStent dislodgment Wire dissectionAortic cusp dissection
Complex PCILM Stenting : Proper angio views don’t miss
ostium IVUS guided Re-intervene : don’t go underneathBifurcation : Jailed large SB –KBT will suffice Reverse crush –Predilation is
mandatoryCTO: Wire handling
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Hopefully she won’t come back again…
Thank you!Thank you!