Transcription
Good afternoon, everybody. Good afternoon, dear friends. And, uh, we are really happy with, uh, all my colleagues to welcome you for this webinar focusing on the complication of bifurcation left main PCI. It's a, uh, really great, uh, uh, honor to have today three fantastic co-operators: Chi Yas, Lego, and Goran Sankovic. The key learning objectives today are to discuss together the potential complications when performing left main PCI. Second, to understand how to minimize the risk of these complications. And to learn, of course, the bailout techniques for this kind of complication.
Today, we have three consecutive cases presented by Goran. We present you a nice case of, uh, uh, dissection. Terry La will present you a case of, uh, side branch occlusion during a true left main PCI. And finally, Yto will present you a very difficult problem of how to manage stent protrusion in the aorta. So, we can, uh, you have the possibility to ask questions on the chat. Do not hesitate. I will receive these questions and I will do my best to transfer these questions to our three speakers. So, I think we can move, uh, to the first case presentation with Goran Sankovic. Goran, are you ready?
Yes, I'm, I'm ready. And thank you very much for the opportunity. Uh, I selected a iatrogenic left main coronary artery dissection. So, here is the case. Young female, 48 years old, with chest pain on exertion and rheumatoid arthritis. She had a positive treadmill stress test. Echo showed normal LV function without segmental wall motion abnormalities. So, she was scheduled for regular diagnostic coronary angiography. Here is a coronary angio, left coronary artery in two different projections, showing no, uh, coronary artery disease with significant stenosis. And then we have an additional projection of the left plus projection of the right, showing that actually this was a so-called normal coronary angio. And what happened next is sudden onset of chest pain 15 minutes after we finished coronary angiography.
Here is the ECG, extensive changes on ECG. And of course, we urgently brought the patient back to the cath lab. And this was a small injection into the left main, which showed a clear coronary artery dissection line. We immediately stopped at this point. And the question is, what to do next? So, uh, there are multiple approaches, but I think the key one is to stay calm, to stop injecting contrast, and then reconsider options.
John, no, I think that, uh, if we can stay on this view and, uh, looking at the, if you can show us the the left main dissection, okay? And, uh, all of you, uh, uh, see the, you immediately feel the difficulty of this left main dissection, which is a large dissection involving all the lengths, at least all the lengths of the left main. So, what do you do? Gan, say first, no more angio. Cheri, have you an idea?
Yeah, I think there are many options, but as it was said by, uh, Goran, no more angio, because each angio you do, you may increase the dissection. And, uh, so I think it's very important to stop injecting and to think about how to, to find the solution, to rewire in the true lumen.
Jasek, do you agree?
Absolutely agree. We should imagine that this is a life-threatening condition here. And with every contrast injection, we can just worsen the situation and not improve the situation. So, the way to go is just to take, first, a wire, try to introduce to the LAD, then the second one to the circumflex, because both wires have to be protected if we have this dissection which is so long in the left main. And of course, afterwards, we need to confirm if we are in a true lumen or not. In my practice, the best way to do that is just to use intravascular ultrasound.
Jasek, you say you replace the wire in the, in the, which kind of wire in this particular case, you, you will use a standard wire or a specific wire?
I would start with just the regular, uh, BMW wire. I would avoid to use hydrophilic wires as a first attempt. Of course, if they are not successful, then we can, we can deliberate and choose another ones. But usually, I will go with a regular run-through intermediate or or BMW Universal.
Okay, so everybody agrees to the necessity to and the usefulness to use a, uh, intracoronary evaluation by IVUS. So, Goran, what did you do?
Yeah, yeah, thanks. As, as already discussed, wisdom comes from bad experiences. So, we had some bad experiences in the past and we learned that unless we use intravascular imaging, it's very difficult to make sure that you are inside the true lumen. Stenting the false lumen is potentially dangerous and can occlude major branches like LAD or the circumflex. So, this is IVUS. So, no contrast wiring, as both Terry and Yasek said, wiring with run-through in this case, both vessels blindly, no contrast injection. And then I was, I was on the LAD wire. And what you can see here, you see actually on the cartoon on the right hand side, in red square, it's a large false lumen with very weak vessel wall structure and very small green true lumen. So, our goal is to use IVUS catheter and then try to reposition the wire inside the true lumen.
Here is a schematic presentation. So, currently, what we have is IVUS catheter which documents that both wires in the circumflex and the LAD are in the false lumen. And we tried to get the third wire in the true lumen. After some attempts, we were able to see on IVUS. And you can see here on the again on the cartoon on the right hand side, red area is again false lumen, now with the IVUS catheter still in that lumen. But we see now a wire which is convincingly placed inside, green, inside the true lumen. And this is the most important step to make sure by imaging that we have a wire inside the true lumen before proceeding. We reposition IVUS catheter on that wire which was in the true lumen. And now what we see again on the cartoon, we have a larger green true lumen with IVUS catheter inside the true lumen. And we see false red area outside. This is the moment that we seal the dissection stenting from the ostium of the left main towards the LAD, then POT, and then a shallow, really small injection of contrast to check the flow.
What we see here after NC balloon 4.5, is an angiogram with slow, uh, flow. But we don't clearly see distal dissection. We wanted to make sure that we seal completely dissection distally. So, we go inside with the IVUS catheter. And you see passage of the catheter throughout the stent, going slowly distally. And you will see now between 4 and 6 o'clock, actually 4 and 6 o'clock, you will see here residual dissection. So, this was IVUS documented unsealed dissection distally. So, we added a second stent. And this is the final angiographic evaluation showing, uh, good flow and no distal dissection. So, this is ECG post PCI immediately after stenting dissection. She's symptom-free and she had an uneventful hospital course. There was a small rise in drop in troponin, 660, but no, uh, segmental wall motion abnormalities on echo. So, if you have any comments on how to make this even better and more user-friendly, let's discuss other alternative options. I have.
Excellent. And thank you. It's a great, great case. And, uh, really, you demonstrate brilliantly how to, uh, fix this dissection first, how to be sure that we are in the true lumen. And, uh, everybody saw this difficulty to be sure to be in the true lumen if you are not using IV evaluation. I have, uh, just before starting the treatment, I have a question coming from the chat, Goran, by Dr. Ian S. What's the cause of the dissection? Iatrogenic versus spontaneous?
Yes, but you know, on the first angiograms, there was no dissection. Patient was free of symptoms on three different angiograms of the left coronary artery. There was no dissection inside the left main. And 15 minutes later, she actually had a sudden onset of chest pain. And on a small injection in the left coronary, it was really a clear dissection plane inside the left main. So, I believe it's a diagnostic catheter which probably was not positioned properly and created this dissection. So, I believe it's iatrogenic.
A second, uh, question in the etiology of this, uh, of this dissection. Question coming from Dr. Sayan Nay Nan. Whether the ostium of the left main is involved? In other words, when you did the coronary angiography, maybe there was a lesion at the ostium, and if this can be considered coronary syndrome?
Actually, on the IVUS, the ostium of the left main was spared. Actually, I believe that mechanistically, insertion, maybe uncontrolled entrance of the catheter inside, created inside the body of the left main dissection, which then with flow expanded this. So, the ostium was spared on IVUS. There was no dissection at the ostium. But when we stented, we had to cover because there is always a possibility to have a retrograde transmission of the dissection. And for that reason, we stented from the ostium of the left main.
I have another question concerning the the ostium of the circumflex from Dr. Adrian Sebas. But we will come back in a few seconds. Just now, a question when we see this kind of large dissection, of course, you will take such six French at least guiding catheter in order to have the possibility to use a Corsair. And what will be the shape of the guiding catheter? You will select a standard shape or in this particular case, a special shape?
Yeah, uh, so, Judkins has a less traumatic tip. And I think the choice should be towards a less traumatic tip instead of an extra backup catheter, especially when we document that there is a dissection plane already existing with the engagement of the EBU. I think it may worsen the situation.
We can ask questions to, uh, our colleagues Terry and Yasek, of course. Goran demonstrated the, the, really the usefulness of the IVUS. But if we have no IVUS in the cath lab, or if we have a really small experience with IVUS, what's the other option?
So, if we, of course, we, what we need to confirm in these cases is that we are in the true lumen with the wire, to avoid implantation of the stent in the false lumen, which would be probably fatal in such a case, especially if you do that in the left main. So, maybe the option that we can use is to use a microcatheter, going very distal to the vessel, and doing some small injections. We can clearly see if we just fill the false lumen or we see side branches and the distality of the vessel. It could be a good confirmation of where we are. Of course, if the wire in the distal part of the vessel is negotiating in side branches, especially many side branches, it's not usual in small vessels that this hematoma protrudes to small vessels to the left main. It can, to the circumflex, like it was shown by Goran, that both wires in LAD and circumflex were in the false lumen. But if the wire is going in the distal part of the vessel to, to, to small septal branches or or diagonal branches, it's also a good sign. However, it's not 100% sure that you are in a true lumen. So, this is, this is my, my, my advice.
Thank you, Yasek. And this about a question coming from Dr. Julio Andrea and Luis Delgado. Jerry, where the other comment on this?
No, I, I, I suspect that I don't know. Goran, you didn't say if the patient, because of rheumatoid arthritis, were on corticosteroids? Maybe she was. And I think it's a risk factor for spontaneous dissection, traumatic dissection during cogram. So, she was on corticosteroids?
I don't have those exact data now, but you are right. And with lupus or that kind of weakness of the vessel wall, could be an additional factor for enhancing the chance for having traumatic dissection. Very good that we usually see such complications in rather younger patients and especially in those patients without severe atherosclerosis. And probably there are some connective tissue disorders which are asymptomatic and difficult to be diagnosed which are behind this. But so, this is very difficult to predict even such a situation.
Yeah, we saw on the IVUS that there is no actual atherosclerotic disease in the vessel wall. So, you are right, maybe connective tissue disease could be a predisposing factor also in this particular case.
Goran, what kind of, uh, guide wire do you use? You are using the standard guide wire you use for all the PCI?
We start with standard. And I said, in this case, it's our workhorse wire, at least for my, my cath lab. It's either run-through or BMW Universal. My personal approach is run-through. And then, of course, you have to increase the stiffness in case you are not able, with IVUS guidance, to re-enter in the true lumen. A slightly stiffer wire may help.
So, I have a question again on IVUS by Dr. Cheri. How do you know that you are in the right lumen with IVUS?
Yeah, it's an excellent question. And if you see the vessel wall structure on the images, you see actually adventitial tissue, which is a very lousy, no clear vessel wall structures, while on the other lumen, which is like in aortic dissection, compressed and small true lumen, you see more clear contour of the vessel wall.
So, that was there is another question from Dr. Fuhrman, but we will come back at the end. So, stay here with us. We will come back to your question. I have just a question, Goran. Sometimes we use, you know, to be sure that we are in the right lumen, we place the wire in the septal branch or diagonal branch of the LAD. Can you really rely on that, or this could be discussible?
I think to make sure, imaging shows you clearly where the position of the wire is. But positioning a wire in different small side branches could be one of indirect signs. What I would suggest in that case is to go again with the microcatheter, remove the wire, and wait for the backflow. If there is a backflow, this is additional confirmation that you are probably in the true lumen. Don't rush with injection of contrast. This is the key. You don't need to rush as long as the patient is hemodynamically stable. Try to do every effort not to stand the false lumen.
Thank you, Goran. I have another question coming from Dr. Nadim. The question is the following: If IVUS is not available in the cath lab, can we carefully slide a small vessel on the wire to see whether we are in the lumen? Can you recommend that or not?
I didn't get the question. What should, can we do? You have the wire and can we advance the balloon slowly, carefully, gently, in order to see if the wire, the balloon can cross and signification of the that we are in the right channel?
I wouldn't recommend that because, for myself, having no resistance actually enhances the risk that you are in the false, not in the true lumen. So, I believe microcatheter or preferably have imaging possibility in the cath lab. IVUS preferentially because you don't need to inject contrast.
So, I have the last question coming from Dr. Farra. He said that it's not flow-limiting, the dissection is not flow-limiting. Can we manage it conservatively as in a non-left main dissection? Is it different?
Left main, 80% of myocardial mass of the left ventricle is at risk with a clear angiographically clear dissection of the left main. So, I believe this is not something to be managed conservatively. It has a high risk. And I really recommend to have IVUS, know what are the steps, follow the steps, and have a colleague with experience with you in the cath lab, two seniors to discuss every step before proceeding to the next. I believe dissection of the left main is a life-threatening situation. And you should really do your best to evaluate, follow the rules, and seal it.
Thank you. It's very clear. So, we don't. Thank you, Goran, again. We learn a lot. Thank you. First, we have all the time to treat it. We cannot leave this kind of dissection in the left main. And second, you insist, Goran, on the, the usefulness of the IVUS assessment in order to be sure that we will place the wire in the right channel. I had a question at the end. You placed the, the, the stent in the left main and the second in LAD. There was a question from our, from our friend, concerning the ostial circumflex. Do we need to, do we need to rewire the circumflex? Do the kissing balloon or the POT is enough for the left main?
We did POT with 4.5. We went with IVUS. We saw opening of the image towards the circumflex. So, we decided to stop at that point. We did not decide to do, to expand in PCI and rewire and do kissing. In our view, with IVUS documentation of non-compromised, widely open ostium of the circumflex, we stopped at that point. It's an important remark that even if you, if you have still visible dissection in the circumflex, but the origin of the dissection is fixed with the stent in the left main, and you have good flow without symptoms of ischemia, usually this dissection heals in time spontaneously. So, you don't need to implant another and another stent because it doesn't help the patient, especially for long-term follow-up.
Thank you, Yasek, and thank you, Goran. Goran, two herbs, two, you know, to summarize the case.
So, two words: it happens. It's possible, even with the most careful maneuvers with the catheter, to dissect the left main. Now, I think we showed what are the proposed steps, how to safely manage this complication and to prevent. Of course, you need to follow the rules of having coronary angiography with the good position, coaxial position of the diagnostic catheter, good pressure curve, no damping before injecting. Probably we omitted some of these steps. Thank you, Goran, for this great case. It was a great learning case. We learned a lot of tips and tricks. And now it's time to move to the second case, which will be presented by Jerry Ra. And Jerry, are you ready for the case presentation?
Thank you, Johan. It's a really pleasure to be part of this great session about complications when dealing with the left main. So, this is an 81-year-old woman who had angina since two months. And she was admitted for cogram. As you can see, she had a lot of risk factors: hypertension, dyslipidemia, diabetes mellitus. Echo was normal, by EO ejection fraction was 50%. Renal function was also normal. But she had a previous chest irradiation for breast cancer many years ago. Please notice that she is 52 kg and the size is very small. So, she is 148 cm.
So, this is the view in the, uh, left coronary system. You can see that it's clearly a Medina 111 bifurcation lesion with a lot of disease everywhere in this left main. And I want to remind you a few rules which, in my view, are very important when dealing with left main PCI. The first is that it's very important to have an optimal view to see the separation of the two vessels, the LAD and the circumflex, and to see the ostium of the left main. Usually, it's a cranial view, not the spider view. No, before starting the procedure, where are the difficulties? And discuss with other colleagues or having a proctor if needed. It's also very important to wire both branches because you secure the procedure with two wires in both branches. And very important also to respect the fractal law in order to avoid carina shifting when you treat one of the two branches. A POT is a crucial step of every bifurcation. Now, we know that whatever the technique, one stent, provisional, two stents, de-crush, we need POT several times during the procedure. And of course, it's very important also to learn how to solve difficult side branch success before stenting, but also after stenting. So, maybe we can, uh, discuss about this case before starting.
I think, yes. Um, I have a question. You, you talked about the, the importance of to have a right view of the, the left main bifurcation. So, what are the, the views that you use in daily practice?
Yeah, so, so we have two views to see the bifurcation. One is anteroposterior caudal, usually to see the ostium of the left main and the bifurcation between LAD and circumflex. But to see nicely the separation between LAD and circumflex, the best view is a spider view. And it's very important because if you want to do a POT at the right place, you need to have this nice separation of the two branches. And, uh, we need also a third view, which is the ostium of the left main. And usually, you can see clearly the ostium, not in this particular view, but in a cranial view, some anterocranial. So, 1040 for example, or some craniocaudal. So, depends on the patient. So, these three views are very important. Of course, the working view in order to reduce the risk of X-ray exposure, etc., is the anteroposterior caudal view.
Okay, I think we can, you, we can move on the case in order to see what you have done.
Yeah, okay. So, this is anteroposterior caudal view, as you can see, a lot of disease everywhere in this left main, but also in the LAD and in the circumflex. So, we, when we think about the case, we start to make some measurements. Of course, you can do intracoronary imaging also, but it's very important to have an idea of this vessel before starting. So, the guide is six French. So, it's a 2 mm in diameter. And you can see already that the LAD and the circumflex are very small. So, LAD about 2 mm or less. Of course, there is a lot of disease. The circumflex is about 2.5. So, if you make calculations to see what should be the correct size of this left main, it's about three. So, it's very small. So, I think maximum could be 3.5. And IVUS is very, is not very useful because there is a lot of concentric enlargement of the elastic membrane. And then you don't know exactly what is the size. So, in this case, the operators, after a lot of discussion, they decided to use a three stent in order to cover the left main and the proximal LAD. You see that there is still some waste on the balloon in this case. It was done after some predilation. And this is a result after stenting left main to LAD. We have occlusion of the circumflex. So, of course, at that time, the patient had ST segment elevation in the lateral territory. She had chest pain. So, what is the mechanism of this occlusion? I think we can, of course, discuss about that. But you know that there was a lot of atherosclerotic burden in this vessel. The stent was sized mainly according to proximal reference. So, it increased the risk of carina shifting and occlusion of the circumflex. And, and so, what to do at this level? So, Goran, you have this kind of occlusion of the origin of the left circumflex after stenting, what do you do?
The first step for me is to precisely position the POT balloon, do POT, expand better the proximal segment inside the left main. Hopefully, by doing POT, you actually open the struts in front of the ostium of the circumflex and you may provide some flow, visualize the ostium of the circumflex. And if the patient's clinical presentation is stable, this gives you some time after POT to try to rewire. If POT does not work, there is always, because of the discrepancy in diameter between the left main and the ostium of the LAD and circumflex, there is always a possibility to go with a small balloon on the jailed wire behind the stent and reestablish flow. Sometimes, just by passing the balloon, even without inflation. Very important, if you aim to do jailed wire balloon on a jailed wire, it's very important to put first inside the stent on the LAD wire, a non-inflated balloon, because maneuvers on the jailed wire may damage the stent, and this deformation could prevent entrance inside the stent and compromise the whole procedure. So, first step, balloon in the LAD on the LAD wire inside the stent. And then a small one or 1.1, 1.25 balloon behind the stent.
Okay, so we have the possibility of rewiring directly, second, rewire after doing the POT. And if it's not working, the technique of the jailed wire and the jailed balloon. Terry, what did you do?
Okay, so Jean, we can, as you said, we can try to rewire. But I think it's not, in my opinion, as Goran said, it's not the first option because it will be very difficult because you have really pushed the carina and it's closed. But may solve the problem. And we have a wire in the circumflex. So, we can use a wire to reopen the circumflex with a small balloon. So, this is the case. We wired the circumflex because it was the most difficult one, the LAD. Then we stented from left main to LAD. But because the stent was too large, then we have pushed the carina and it's closed. The POT by extending the proximal part of the left, of the bifurcation, will completely modify the stent and you may reopen the circumflex by just doing a POT. Of course, of course, it's very important to have the POT at the right place. And that's why the fact that you have two wires helps you to put the distal part of the balloon at the right place. And in this case, you have to go in the spider view. So, of course, if you are able to have flow, then you can continue the procedure. And instead, if you are not able to restart the flow with a proximal optimization technique, you can use a balloon outside. It was described nicely by Goran and by doing that, and you put the balloon up to the bifurcation, you restart the flow, and then you can rewire the side branch with the sub wire.
So, in this case, what we have done is just to use proximal optimization technique. You, you see that we have the other wire in the circumflex. Here, we have used a 3.5 non-compliant balloon to do the proximal optimization technique. And after that, you can see that now we have a flow in the circumflex at the ostium. And it was possible to find the lumen, to go in the circumflex. Then after that, you can just open the lesion in the circumflex, relocate the carina by opening the strut towards the circumflex. And so, this is the key kissing inflation. Now, you have the carina in the center of the bifurcation, which is very important. And then you can position a stent as a T or TAP configuration, deploy the stent, then do a kissing balloon inflation, and finalize with a proximal optimization technique. And this is the final result in AP view.
Excellent. So, Terry, we have a question coming from, uh, our colleague Dr. Sharul Islam. It's the question is concerning the prevention. How to prevent this kind of side branch occlusion when we see your the really this critical lesion, which is a left 111 bifurcation lesion? And he has for a double stent technique, starting by a double stent technique here, the usefulness of a DK crush. And it's true that if we use a DK crush, can you hear me? Because I have a problem with the line.
No, the line. The question was concerning the use of two technique immediately, particularly DK crush, in order to prevent this complication. Of course.
So, I think in this particular case, we could have done a DK crush technique, starting with two wires, stenting the circumflex first, or the LAD first, because it's difficult to know which branch is at risk of occlusion. Uh, but we prefer, in this case, we prefer, not to do DK crush. It's a very demanding technique. You need to do three kissing balloon inflations, three POTs. So, it's very demanding. But of course, if you know how to do it well, and if you don't forget any step of the technique, I think it's a very good technique. Uh, in this particular case, I think the operators did not follow the rules, which are not oversizing the stent. So, just respect the fractal law of the bifurcation. And of course, in this case, it's very difficult because there is a lot of atherosclerotic burden. And putting a 2.5 stent in the LAD and the left main looks very, uh, special. But the patient also was very special. She was 142 cm in length. So, uh, so I think the main mistake was using a stent which was too large for this patient and pushed the carina and closed the vessel. But as you, as it was suggested, I think the crush technique can be also a good approach.
Yeah, this question, this comment concerning the two technique and DK crush are also coming from Dr. Christian Poes and Dr. Madhuan and Dr. Hamza Ullah Islam. So, we have a lot of questions concerning the use of two technique in this particular difficult anatomy.
Yeah, but I think in this particular case, we knew that it will be a two-stent technique. The question is, which kind of two technique you use? So, yeah, following the rules of provisional and ending with TAP or or Culotte, or inverted provisional, starting by stenting first the circumflex and then do at the end TAP or Culotte. And the other option is starting directly with the crush technique.
Okay, excellent. Any comment, Yasek or Goran? Maybe if I can, I can add something to this technique that was used by Terry with the POT immediately after stent implantation, instead of going directly with the wire. Because when you experience side branch occlusion, especially circumflex, immediately the patient becomes symptomatic, sometimes if it causes mitral regurgitation also, hemodynamically unstable. So, we want to be very fast with the second wire to try to open the circumflex. And if the stent in the proximal part, if it is appropriately implanted according to the distal main vessel, LAD diameter, it is always undersizing the left main. So, if you are going without POT with the wire, you can go with your wire behind the stent, between the stent and the vessel wall, and engage into the side branch, then dilate with the balloon. And especially if you are not with your balloon on the LAD, like Goran mentioned, you can be in real trouble. So, I believe that it is very important to stress that even if you experience the side branch occlusion, first step should be to do the POT, and afterwards try to rewire to the side branch which is occluded.
Goran, any comment?
Yeah, again, just to clarify, even if you have difficulty after POT to go on a jailed wire, especially in large plaque burden like in this specific case, there is always possibility, and we tested and it works, to use Corsair and create some space on the jailed wire behind the stent. As soon as you detach and you have some space, you can enter with the balloon. And this is something really in the armamentarium that we need to know. These are the options. And as in every complication case, you work slowly, you know, step one, two, and three, and you follow the algorithm in order not to omit some important steps. You can make the procedure much more complex if you skip a step, if you don't do POT, then you can create passing with a wire in and out and make the procedure even more complex than it currently is.
Thank you, Goran. So, thank you, Terry, for this great case. I think that, uh, we learned a lot. It's not an exceptional complication. It's something which happens, you know, in routine practice. So, it was really important to see and to learn the different ways to treat this kind of side branch occlusion. So, um, I think it's time to move to the third case presentation by Yasek, which is a really interesting point and always difficult to manage. It's a problem, the issue of the stent protrusion in the aorta.
Yes, thank you, Johan. Thank you, Goran, for inviting me to this excellent webinar. It's an honor for me. And I would like to share my experience with something which I believe will be more and more often the problem in our cath lab. So, this is a 71-year-old male with a lot of risk factors, comorbidities. And because of that, this patient was disqualified from cabbage and was treated with left main PCI and two strategy on May 2020. And this patient came back to our cath lab on duty day because of the recurrence of rest angina and ST troponin elevation. And what was this patient was scheduled for control angiography. This is what we found. This is the right which is nothing special, without progression of the disease, some lesions, but not critical. And this is the left coronary artery in multiple projections. The distal bifurcation looks fine. We see some stenosis in the ostium of the left main, which is of course very often difficult to be assessed with angiography only. However, definitely there is some narrowing there, also some ulceration. And, uh, we have really good opacification of contrast within the arteries. However, the operators, he had a problem to engage the catheter into the left main. He was afraid. What happens here? How is it so difficult? He was not really sure. He expected maybe this stent is protruding to the aorta. Of course, we try to save exposure of radiation exposure in our patients. So, we use low fluoro mode. And when he switched to high fluoro, he immediately recognized what is the problem. And he found that this stent is protruding into the aorta, not up to 1-2 millimeters, which is very often, but it is like more than five, maybe even one centimeter of the stent which is protruding to the aorta. So, we have a patient who is not a good candidate for surgery, with acute coronary syndrome after left main PCI, with some suspicion of the restenosis or some edge or some stent failure related to the problem which is in the ostium of the left main. And we have difficulty to engage the guide into the stent. So, at this point, maybe we can discuss or, of course, if you wish, I can continue what I did.
Oh, it's true that it's really difficult case, really difficult. And the main question is how to engage the stent with the guiding catheter? How to be sure that we have the wire in the, in the, in the true lumen? So, any comment?
Jerry? No, I think it's, it's as you said, a very difficult case. That's why it's very important when we position the stent during the first procedure to be sure that we are covering the left main at the right place, up to the ostium if needed, but not too much proximal. And sometimes people are using spider view, which I think is a very bad view for positioning the stent at the right place because there is a lot of foreshortening. So, you don't know where it is. So, then when you have to deal with that, I think the best is to wire the left main. And usually, you, at the first attempt, you can go in the left main, but you don't know where you are. Probably you cross outside of the stent and then inside. So, you need imaging to check what you are doing.
Okay, Goran, what type of guiding catheter you will use in this particular situation? Standard Judkins, EBU, or XB, or short left PL?
Personally, I think the best way to control the level of trauma, if it's possible to control on the fluoro, is to use Judkins left. With both TAP and EBU, you have much more extensive trauma at the area of stent protrusion. And imaging is the key. So, the right view, Judkins catheter in order to try to minimize the trauma of the stent with the guide, and imagine.
So, Yasek, what did you do?
Let's go with the case. Before I start, maybe one short rebuttal with the IVUS. Absolutely agree with his statement that the positioning of the stent in the ostium is crucial. However, of course, sometimes it happens that even with good position during stent implant, the stent jumps into the aorta. So, it can happen. What is very important for all of us is to report this in case description if you have it, just report this for the future procedures, for next operators to be aware about this problem before they damage the stent with the diagnostic catheters during the next procedure. So, my approach was quite similar to what you said. So, the femoral arteries were not available, level radial included. So, I needed to use left radial. And I decided to use 40 Judkins left. And it's very important, of course, there are no strict rules, but I did it differently. So, very gentle try to engage with the guide catheter into the stent with a deep bravin. I was quite sure here, what you see, that I am just successful and much more easier than I expected. However, then I introduced the wire and I started to use my intravascular ultrasound probe to confirm I am really going through the stent. And of course, immediately I felt resistance. So, I didn't push because I was afraid that the wire is going through the stent struts, not through the lumen of the stent. I stopped and I used what is my next approach. First is to use a less traumatic guide. And second, I left this wire in the artery to have a to, to much more, much more easier control on the guide. Try to use the second wire with the probe on this wire and to look for the lumen of the stent. And you see how easy it was to introduce the wire. So, again, I was quite sure that maybe now I am successful. But again, I am stucked with my probe. And again, try not to use any force. And especially look on the images of the intravascular ultrasound when you do that. So, you can see that I push the catheter and there is a resistance and still I cannot see the stent. So, it's another probably confirmation that we are going with the wire not through the stent. So, I removed this wire and of course, I repositioned a little bit the guide catheter. And I tried again with wiring, looking for the for the good, for the good lumen. Now, as you can see, I am coaxial with the catheter and I entered. It looks like on angiography that I entered the stent. However, just few millimeters inside the stent, I still feel some resistance. So, now let's again look at IVUS. What I see now? And this is very also important and very easy to recognize. You can see that again, the wire went through the stent struts. And you can see the probe is in the aorta. And the stent is just lateral to the probe. So, again, not a good way to go. So, I was not successful for 15 or 20 minutes with this Judkins left 40. So, I decided to change the catheter for a little bit more aggressive extra backup. Why? Because this procedure was done with six French extra backup 3.5. So, I hoped maybe it would be now easier to engage. Of course, as Goran mentioned, this catheter is more traumatic, especially if you have the stent which is protruding like 1 cm into the aorta. You have to be again very gentle and not very, very fast with this procedure. So, again, it looked that I am in a good position. We see the contrast is going into the left main. So, I wired again without any resistance. And then I tried with the second wire to go with the probe. And as you can see, it was not now so easy. Of course, there was not a good backup from this guide, which was not introduced into the lumen of the stent. And I was not sure. But I didn't want to go with the probe. I just changed the projection, which is also very important. Was in apical or epicranial? It looked like the wire is going through the stent. And now we see, you see that both wires are going through the stent struts. So, again, this was, I felt not comfortable with this extra backup catheter, which is of course my workhorse for for regular left main procedures in 90% of cases. However, I then decided maybe with a smaller curve Judkins, so 3.5, it would be easier to get a control on the catheter and more safer to try to find the lumen. So, this is now again from the left radial. I introduced the 3.5 Judkins. Try to engage into the into the left main. It looked quite okay. But it looked the same for extra backup. So, every time when I am, when I have the feeling that I am in good place, the next step, of course, is to wire and then to go with the probe. And here I didn't record it, but the first attempt was not successful. So, I used the body wire to reposition the guiding. And this is another try with the second wire trying to find a good lumen. And now, fortunately, I was successful. We are in a probe with a in the body of the left main. And I try to pull it back. Of course, we need to do it gently because it's very easy to damage the stent which is in the aorta with the guide, especially if you have any resistance during the pullback of the guide of the IVUS probe. And in the ostium, you can see that probably this stent is fractured. And there is also a lot of soft tissue, which could be the thrombus, which explains why this patient came back with rest angina and troponin elevation. However, what is most important, I confirmed with IVUS that I am going with my wire from the guiding through the lumen of the stent and not through the stent struts. So, now I'm ready to go for PCI if it is necessary. My decision was to perform direct stenting with a short 48, 9 mm long, drug-eluting stent. Of course, positioning is much easier now than before because we see the stenosis and we are still of course inside the stent. So, we would not protrude. But epicranial view, as mentioned, is absolutely crucial. Never do that in spider view or AP. Always LAO cranial, LAO epicranial. Post-dilation with 4.5. And of course, it's time to check the result with intravascular ultrasound. Now, this probe went without any resistance. And we are pulling back again. Try to do it slowly. And here you see the double layer of stents. And as you can see now, the ostium is fully covered. Stent is well opened. It is protruding, but it was not damaged because I was trying to be very careful with all the maneuvers from the guide. But the same time, afterwards, at the end, I dilated with the balloon all the stent which is protruding to the aorta, just to summarize. This is the final injection of the contrast. However, of course, if you want to assess the result, IVUS is more appropriate. So, this is just to check if there are no problems distally with, for instance, wire causing some dissections. And this is just to stimulate the final discussion. The case from the past and very similar. The patient came back after left main stenting for the PCI of LAD. And this was started with right radial approach, not successful. So, we successfully wired the LED and also introduced the probe into the LED very easily. But during the pullback, we have recognized, as you can clearly see here, that that this wire was introduced through the stent struts. And also in this particular case, the probe went very easily through the stent struts. If you don't recognize this and if you go with the balloon and stent and inflate the stent, the balloon in the LAD, and then during the removal of the balloon, you can even withdraw the stent from the left main. Such cases are in the literature. You can find them. And so, knowing that I am not in a good position, I changed to femoral approach, changed into the Judkins guiding catheter. And using my two wires approach, I finally engaged the wire through the stent. And now you can see the pullback. And you can see also now stent distortion. So, during all these maneuvers, before diagnostic catheter, and then first attempt, we damaged the stent in the aorta. Of course, it's not good to leave it like this. Maybe it could be a problem. But it's not if you are going with the wire through the stent. Because then you just need to inflate the balloon appropriately sized. And this is the result afterwards. So, it's very easy to treat such stent distortion, of course, if you recognize it on intravascular ultrasound and your wire is going in a good direction. Thank you very much for your attention.
Thank you, Yasek. It's a really a great case. And thank you to show us all the different steps of the procedure. Um, I have a comment from the coming from the chat from Dr. Jorge Eduardo Sharaga. And they said, which is true, because on the three consecutive cases, he said that much of the success of management to avoid complication would be the support with intracoronary imaging. And we saw in the three consecutive cases the major role of IVUS. Any comment, Goran or Terry?
I absolutely agree with that comment. With time, we learn more and more how more predictable, safer, and optimized results can be achieved using image guidance. And we strongly recommend men to have at least the possibility in case of something going wrong, as you have saw in our cases. Imaging really helped us understand the mechanism and then treat adequately.
Jerry? Yeah, yeah, I fully agree with Goran. I think we need intracoronary imaging at least when something is going wrong. I think it's a, very important. It's one of the recommendations that we made many years ago. Uh, of course, you can use more intracoronary imaging, but at least if something is not clear, if something is going wrong, it's very important to do it.
So, I would like to thank you, uh, all of you. I think it's time to close, unfortunately, because we could discuss one or more hours on this, uh, complication on left main. Thank you for showing us and to share with all the community present today, these three consecutive cases. The first on the dissection of the left main, how to treat, how to deal it. The second of the thrombosis of the occlusion of the side branch after the stent implantation in the left main LAD. And finally, this really, really complex and difficult procedure, how to manage stent protrusion and treating the ostial left main lesion. So, I would like to thank you all of you for the quality of your cases. We learned a lot. And this is, uh, really the main goal of this webinar, of this live webinar, it's to learn tips and tricks, particularly today on this particular session on complications during left main intervention. So, thank you very much. Thank you for all the participants who participate in the chat. And see you very soon in the next webinar. And of course, in May, at in Paris for the next EuroPCR. Thank you. Of course. Thank you. Thank you.
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