Complex PCI: LAD and LCX


Sandeep Sehgal, MD

Patient History

A 69-year-old female with a history of hypertension, diabetes, and obesity had severely stenosed left anterior descending (LAD) and left circumflex (LCX) arteries. The patient successfully underwent high-risk percutaneous coronary intervention (PCI) to restore blood flow using orbital atherectomy and Impella® support.

The patient complained of shortness of breath and was referred for a stress test. The results showed strongly positive anteroapical perfusion defect, suggestive of a large area of ischemia. Coronary angiography revealed critical lesions in the distal left main bifurcation* involving both the LAD and LCX arteries. The patient had a normal left ventricular (LV) ejection fraction of approximately 55% and no mitral regurgitation. The patient was considered to be an appropriate candidate for atherectomy.

Treatment Summary

Right femoral artery access was achieved with an 8 Fr sheath. With ultrasound and fluoroscopic guidance, left common femoral artery access was achieved for placement of an Impella device for hemodynamic support.
The initial angiogram confirmed a severe stenosis in the distal bifurcation* of the left main and a 99.5% ostial LAD stenosis, as well as high-grade stenosis of the mid- and mid-to-distal LAD. The LCX artery at the ostium had a 90% high-grade, stenotic lesion.

The workhorse guide wire was exchanged for the ViperWire Advance® Coronary Guide Wire. Orbital atherectomy of the LAD was first performed using low speed across the distal left main and proximal LAD. The Diamondback 360 was then placed into GlideAssist mode to facilitate smooth removal of the crown, followed by exchanging the ViperWire Advance® for a BMW guide wire.
Predilation of the entire LAD was done with a 2.0 mm x 20 mm balloon followed by the placement of a 2.25 mm x 38 mm Synergy stent in the mid LAD, deployed at 16 atms. The proximal lesion of the LAD was predilated with a 2.5 mm x 12 mm non-compliant balloon, which required the placement of a 2.75 mm x 18 mm stent in overlapping fashion, inflated to 16 atms. A 2.5 mm x 20 mm non-compliant balloon was placed in the ostium of the LCX artery to facilitate kissing stents. A 3.0 mm x 28 mm stent was placed in the LCX artery and a 3.0 mm x 23 mm stent was placed into the LAD in an overlapping fashion, and high-pressure inflations were done in an alternating fashion.
The physician noted that excellent flow was achieved. The patient was hemodynamically stable; therefore, pump support was withdrawn.

Key Takeaways

Orbital atherectomy successfully modified severely calcified lesions and reduced stenosis to allow for the placement of multiple stents.
• With hemodynamic support, orbital atherectomy can help optimize PCI outcomes, even in high-risk patients.
• Orbital atherectomy was accomplished via single insertion of a 1.25 mm Crown. The profile of the Diamondback 1.25 mm.

* Results may vary.
Warning – Performing treatment in excessively tortuous or angulated vessels or bifurcations may result in vessel damage.

Pre & Post Procedure Images


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