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A case of IVUS guide a second PCI in LAD restenosis post stenting

A case of IVUS guide a second PCI in LAD restenosis post stenting. Shenyang Northern Hospital Xiaozeng Wang, Shouli Wang, kai Xu. History （ The first admission ）. Li XX, female, 63 years 2009-5-12 Admission for paroxysmal chest pain more than 9 years and become serious in 1 month

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A case of IVUS guide a second PCI in LAD restenosis post stenting

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  1. A case of IVUS guide a second PCI in LAD restenosis post stenting Shenyang Northern Hospital Xiaozeng Wang, Shouli Wang, kai Xu

  2. History（The first admission） Li XX, female,63 years 2009-5-12Admission for paroxysmal chest pain more than 9 years and become serious in 1 month No DM or Hypertension. Smoked for 20 years. Diagnosis：CHD----UA 2009-5-15:CAG and PCI

  3. The first SCA 2009-5-15 SCA：pLAD 95%stenosis，mLAD 70% stenosis ，dLAD 50%stenosis. LCX is normal. RCA Is normal and small.

  4. The first SCA

  5. The first PCI 2009-5-15 The firstPCI in our hospital：JL3.5 6F/BMW，The proximal and middle segment of LAD are pre-dilated with sprinter 2.5/15mm，blood flow TIMI 3 grade

  6. The first PCI 2009-5-15 PCI：pLAD is implanted with an Endeavor 3.0/24mm,the middle segment is implanted with an Endeavor 2.75/24mm，the two stents are overlap with each other,Post-extension to LAD stents with Endeavor 3.0/24mm 8-10atm

  7. The first PCI 2009-5-15 PCI：the results

  8. History（The second admission） • 术后服阿司匹林 0.3 1/日，1个月后0.1 1/日；氯吡格雷75mg 1/日；阿托伐他汀 20mg 1/晚( aspilin, clopidogrel, and torvastatin) • 术后5个月（再次入院前1个月）始再发心前区疼痛，多于活动时（步行500m左右）发作，休息约2min后缓解 There was precardia ache again from the implantation latter 5 month.Most attack appear suddenly when he walks about 500 meters and alleviates approximately after 2 minutes’ rest . • 2009-11-11再次入院( re-admission)

  9. The second SCA 2009-11-12SCA：The primary stents in the proximal and middle segments of LADare 90-95% restenosis. The lesion involve in LMand LCX，the distal segment of LCX is 30% stenosis. RCAis same to the first time

  10. The second SCA 2009-11-12 SCA：The primary stents in the proximal and middle segments of LAD are 90-95% restenosis and the lesion involves in LM and LCX

  11. STRATEGY • LAD支架内严重再狭窄(seriousrestenosis) • LM及LCX受累(involve in LM and LCX) • PCI及CABG双适应证 (doubleindication) • 家属选择再次PCI(select re-PCI) • 拟IVUS指导下完成再次PCI (IVUS guide PCI) • 计划先植入LAD-LM，穿网眼植入LCX-LM（裙裤支架技术, culotte technique）

  12. IVUS Restenosis of stent in LAD The ostia of LCX is involved The diameter of LADdistal segmentis 3.0mm, the proximal segment of LADis 3.5mm. The restenosis of areais 69.2%. The minimum lumen area is 2.3mm2.

  13. IVUS Stenosis of LADdistal segment Restenosis of stent in p-LAD

  14. The second PCI 2009-11-12 PCI：JL4.0 7F/Runthrough，The primary stent in m LAD are pre-dilated with Ryujin 2.5/15mm and implant a Partner 3.0/36mm stent in the d LAD 2009-11-12行PCI：JL4.0 7F/Runthrough，LAD中段原支架内预扩（Ryuijin 2.5/15mm），于LAD远段植入Partner3.0/36mm

  15. A Partner 4.0/24mm stent is implanted in LM - pLAD. The ostia of LCX is pressed about 70%.LM-LAD is dilated by Ryujin 2.5/15mm and LM-LCX is dilated by 4.0/24mm stent balloon. A Partner 4.0/18mm is implanted in LM-LCX. The proximal stent is in the same level of ostia of LM 于LM-LAD近段植入Partner 4.0/24mm(与中段支架相连)，LCX口部受压70%； LM-LAD与LM-LCX对吻扩张（支架囊4.0×24mm与Ryujin 球囊2.5×15mm)，于LM-LCX近段植入Partner4.0/18mm，支架近端与LM平齐

  16. A Partner 4.0/24mm stent is implanted in LM - p LAD. The ostia of LCX is pressed about 70%.LM-LAD is dilated by Ryujin 2.5/15mm and LM-LCX is dilated by 4.0/24mm stent balloon. A Partner 4.0/18mm is implanted in LM-LCX. The proximal stent is in the same level of ostia of LM 于LM-LAD近段植入Partner 4.0/24mm(与中段支架相连)，LCX口部受压70%； LM-LAD与LM-LCX对吻扩张（支架囊4.0×24mm与Ryujin 球囊2.5×15mm)，于LM-LCX近段植入Partner4.0/18mm，支架近端与LM平齐

  17. The second PCI The result of kissing dilate (Avita balloon 4.0/15mm in LM-LADand balloon of stent 4.0/18mm in LM-LCX）

  18. IVUS result after the second PCI of LAD Stent in LM-LCX adherence well，lumen area 9.9mm2. Three stents in LADand LMadherence well ，lumen area of dLAD almost 4.8mm2，lumen area of PLAD almost7.8mm2.

  19. 支架内再狭窄病变处理的体会： • judge the target vessel stenosis degree PCI术前行IVUS检查，有利于判断靶病变程度、范围 • instruction value of IVUS • 第一次PCI于LAD近段置入直径3.0mm支架，依据冠状动脉造影结果满意。第二次PCI前行IVUS检查明确LAD近段血管直径3.5mm，LM 4mm，选择了直径4.0支架，显示IVUS的指导价值 • PCI术后的IVUS检查可检测支架贴壁情况，决定手术终点 • LM病变、前三叉病变的介入治疗，建议常规行IVUS检查并且对吻扩张要充分 • obviate select stent smaller than vessel 与血管直径比较置入直径较小的支架可能是导致其再狭窄的重要原因，因此在支架选择上及后扩张时要强调最终管腔大小

  20. Thanks

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