Yonsei Med J.  2017 Sep;58(5):1066-1070. 10.3349/ymj.2017.58.5.1066.

Successful Treatment of Unprotected Left Main Coronary Bifurcation Lesion Using Minimum Contrast Volume with Intravascular Ultrasound Guidance

• Lee OH
• Ahn CM
• Kim JS
• Kim BK
• Ko YG
• Choi D
• Jang Y
• Hong MK

• KMID: 2418948
• DOI: http://doi.org/10.3349/ymj.2017.58.5.1066

Abstract

Contrast-induced nephropathy (CIN) is a serious complication in patients undergoing percutaneous coronary intervention (PCI), and is associated with higher morbidity and mortality. The limiting volume of contrast medium is safest and most reliable strategy for CIN prevention. Intravascular ultrasound (IVUS) serves as an attractive alternative imaging tool to angiography in many steps during PCI, thereby reducing the use of contrast agents. Here, we reported a case of successfully treated unprotected left main bifurcation lesion with heavily calcified and diffuse lesion under the IVUS-guided PCI using low volumes of contrast dye of total 12 cc in an elderly patient.

Keyword

Contrast-induced nephropathy; intravascular ultrasound; contrast media

MeSH Terms

Aged
Contrast Media/adverse effects/*chemistry
Coronary Angiography
Coronary Vessels/diagnostic imaging/*pathology/*surgery
Humans
Male
Percutaneous Coronary Intervention
Treatment Outcome
Ultrasonography, Interventional/*methods
Contrast Media

Figure

• 

  Fig. 1 Initial angiography is shown. There were significant stenosis of left main coronary artery, proximal left anterior descending artery with heavy calcification and ostium to proximal left circumflex (A-D). Right coronary angiography showed total occlusion of distal right coronary artery (E) which was successfully treated with stent implantation (F).

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  Fig. 2 Pre-intervention coronary angiography is shown during staged percutaneous intervention with low contrast volume (6 cc) (A) and pre-stent intravascular ultrasound images are shown (B-F). Minimal lumen area of ostial left circumflex artery was 2.5 mm2 (B) and the vessel size of distal reference segment in left circumflex artery was about 4.0 mm (C). The vessel size in the left main coronary artery was about 5.5 mm (D). Minimal lumen area of proximal left anterior descending artery was 2.4 mm2 (E) and the vessel size of distal reference segment in left anterior descending artery was about 3.8 mm (F). Optimal results were initially confirmed with post-stent intravascular ultrasound examination [minimal lumen area was 8.5 mm2 in left anterior descending artery (H) and 7.4 mm2 in ostial left circumflex artery (I)]. Then, final post-stent angiogram was performed after confirmation of optimal results of two stent implantation in left main bifurcation lesions with intravascular ultrasound (G).

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  Fig. 3 Transducer of intravascular ultrasound is located in left circumflex artery (arrow, A) and left anterior descending artery (arrow, B) on fluoroscopic images, which was useful to determine the distal landing zone of stent. Two stent technique in a culotte fashion was performed with fluoroscopic guidance and without use of contrast dye based on the angiographic and IVUS findings (C and D). After final kissing balloon inflation (E), final second angiography with 6 cc contrast injection revealed successful results (F).

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