1 provisional T stentingigakukai.marianna-u.ac.jp/idaishi/www/324/19-32... · 14 Louvard Y, Lefe...
Transcript of 1 provisional T stentingigakukai.marianna-u.ac.jp/idaishi/www/324/19-32... · 14 Louvard Y, Lefe...
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)*+[\:]�^�"_`�)*+L[\!"type A TU� 2� WX�^�"_`�)*+[\:� 5K YZabLcKdeH2)*+Lfg!" type B TU �provisional T stenting�� 3� Yhi� 2O�)*+LjZ�[\!" type CTU�4� <=>kl� 2O�)*+L[\:mn�0deH2fg)*+[\Lco type D TU��"13��pqr��� Lefe◊vre <N type 2� LMT 34�
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Figure 1. Right coronary arteriogram.
Right coronary artery in �A� LAO and �B� AP cranial view, showingtotal occlusion sending large collaterals to left coronary artery
�arrow�.LAO: left anterior oblique, AP: anteroposterior.
Figure 2. Left coronary angiogram.
Left coronary artery in �A� RAO caudal showing 99� ostial stenosisof the LAD �arrow� and the ostium of the obtuse marginal artery ofthe LCX, and �B� LAO cranial view showing moderate stenosis ofthe distal part of the LMT �arrow�.RAO: right anterior oblique, LAO: left anterior oblique, LAD: left
anterior descending coronary artery, LCX: left circumflex coronary
artery, LMT: left main trunk
LMT 34� !"&'()*+[\v 391
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Figure 3. Percutaneous transluminal coronary angioplasty �PTCA�.A: The lesion was stenting with a 3.0�16 mm NIR stent from LMT to LAD. B andC: After stenting, there was aggravation of the LCX ostial stenosis. D: An
additional balloon dilatation using a 3.0�20 mm Hayate PTCA balloon was
performed through the metallic structure of the NIR stent struts. E: After balloon
dilatation, there was still aggravation. F: A 3.0�15 mmMulti-Link stent was implant-ed across the metallic structure of the NIR stent.
LAD: left anterior descending coronary artery, LCX: left circumflex coronary
artery, LMT: left main trunk
Figure 4. Left coronary angiogram after procedure.
Left coronary artery in �A� RAO caudal, and �B� LAO caudal view,showing successful stenting with no residual stenosis. RAO: right
anterior oblique, LAO: left anterior oblique,
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¢�, Express stent �Boston©ª� «¬¢�14���� LMT��/ ����������������� ®¯-�'���°��.� ±²����*HIP³������®z LMT *´µ[\�P� AMI ��' provi-
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1� Quigley RL, Milano CA, Smith LR, WhiteWD, Rankin JS and Glower DD. Prognosis
and management of anterolateral myocardial
infarction in patients with severe left main dis-
ease and cardiogenic shock. The left main
shock syndrome. Circulation 1993; 88 �Part 2�:65�70.
2� Park SJ, Lee CW, Kim YH, Lee JH, HongMK, Kim JJ and Park SW. Technical feasibil-
ity, safety, and clinical outcome of stenting of
unprotected left main coronary artery bifurca-
tion narrowing. Am J Cardiol 2002; 90:
374�378.3� Takagi T, Stankovic G, Finci L, Toutouzas K,Chie#o A, Spanos V, Liistro F, Briguori C,
Corvaja N, Albero R, Sivieri G, Paloschi R,
Mario CD and Colombo A. Results and long-
term predictors of adverse clinical events after
elective percutaneous interventions on unpro-
tected left coronary artery. Circulation 2002;
106: 698�702.
Figure 5. NIR stent.
A, Expanded NIR stent transforms into a diamond-like mesh of
cellular design. B, The stent cellular design was made from U joint
to obtain flexibility and thicker C joint to obtain rigid sca#olding of
the vessel wall.
LMT ��¼P����������~ 393
175
4� Brueren BR, Ernst JM, Suttorp MJ, ten BergJM, Rensing BJ, Mast EG, Bal ET, Six AJ and
Plokker HW. Long term follow up after elec-
tive percutaneous coronary intervention for un-
protected non-bifurcationl left main stenosis:
is it time to change the guidelines? Heart 2003;
89: 1336�1339.5� Topaz O, Warner M, Lanter P, So#er A, BurnsC, DiSciascio G, Cowley MJ and Vetrovec
GW. Isolated significant left main coronary
artery stenosis: angiographic, hemodynamic,
and clinical findings in 16 patients. Am Heart J
1991; 122: 1308�1314.6� von Essen R, Lambertz H, Schmidt W, RustigeJ, Uebis R and E#ert S. Successful recanaliza-
tion of a left main coronary artery occlusion.
Am J Cardiol 1984; 53: 356�357.7� O[Keefe JH Jr, Hartzler GO, Rutherford BD,McConahay DR, Johnson WL, Giorgi LV and
Ligon RW. Left main coronary angioplasty:
early and late results of 127 acute and elective
procedures. Am J Cardiol. 1989; 64: 144�147.8� Wong P, Wong CM, Ko P and Fong PC.Elective stenting of unprotected left main coro-
nary disease. Cathet Cardiovasc Diagn 1996;
39: 347�354.9� Macaya C, Fernando A, I�iguez A, Goicolea J,Hernandez R and Zarco P. Stenting for elastic
recoil during coronary angioplasty of the left
main coronary artery. Am J Cardiol 1992; 70:
105�10710� Tan WA, Tamai H, Park SJ, Plokker HW,
Nobuyoshi M, Suzuki T, Colombo A, Macaya
C, Holmes DR Jr, Cohen DJ, Whitlow PL and
Ellis SG; ULTIMA Investigators. Long-term
clinical outcomes after unprotected left main
trunk percutaneous revascularization in 279
patients. Circulation 2001; 104: 1609�1614.11� DeLezo JS, Medino A, Romero M, HernandezE, Pan M, Delgado A, Segura J, Pavlovic D
and Wanguemert F. Predictors of restenosis
following unprotected left main coronary stent-
ing. Am J Cardiol 2001; 88: 308�310.12� Lefe◊vre T, Louvard Y Morice MC, Dumas P,Loubeyre C, Benslimane A, Premchand RK,
Guillard N and Piechaud JF. Stenting of bifur-
cation lesions: classification, treatment, and
results. Cathet Cardiovasc Intervent 2000; 49:
274�283.13� Lefe◊vre T, Louvard Y, Morice MC, LoubeyreC, Piechaud JF and Dumas P. Stenting of
bifurcation lesions: a rational approach. J In-
terv Cardiol 2001; 14: 573�585.14� Louvard Y, Lefe◊vre T and Morice MC. Percu-taneous coronary intervention for bifurcation
coronary disease. Heart 2004; 90: 713�722.15� Nakamura S, Saito E, Miyauchi T, YokoyamaJ, Kanazawa A, Hayama Y, Hozawa K, Naka-
mura S, Nakamura H, Yamamoto K, Koyama
J, Makishima N, Keida T, Okumura H, Mat-
sukawa S and Ohira H. Stenting of coronary
bifurcation lesions: Y-stenting, T-stenting, sin-
gle stenting, immediate and long-term results�multicenter registry in japan�. Circculation2002; 106 �Suppl 2�: 2�483.
16� Wong P, Tse KK, Chan W, Ko P and Tai YT.Treatment of bifurcation stenosis with the mul-
ti-link coronary stent. J Invasive Cardiol 1998;
10: 34�41.17� Almagor Y, Feld S, Kiemeneij F, Serruys PW,Morice MC, Colombo A, Macaya C, Guer-
monprez JL, Marco J, Erbel R, Penn IM, Bo-
nan R and Leon MB. First international new
intravascular rigid-flex endovascular stent
study �FINESS�: clinical and angiographic re-sults after elective and urgent stent implanta-
tion. The FINESS Trial Investigators. J Am
Coll Cardiol 1997; 30: 847�854.18� Gobeil F, Lefe◊vre T, Guyon P, Louvard Y,Chevalier B, Dumas P, Glatt B, Loubeyre C,
Royer T and Morice MC. Stenting of bifurca-
tion lesions using the Bestent. Cathet Cardio-
vasc Intervent 2002; 55: 427�433.
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Abstract
Provisional T Stenting for the Left Main Coronary
Trunk Lesion in a Patient with
Cardiogenic Shock
Tomoyuki Kunishima, Toshio Sasaki, Hideshi Aoyagi, Ken Kongoji,
Katsuhiko Tsuchiya, Masahiro Yamauchi, Hidetaka Tochiki,
Nobuyuki Hashimoto and Fumihiko Miyake
A 67-year-old man was referred to our hospital with angina pectoris. While in hospital, he suddenly
developed severe chest pain and shock. Cardiopulmonary resuscitation and circulatory support were started
immediately. Emergency coronary angiography showed chronic ostial occlusion of right coronary artery,
99� ostial stenosis of the left anterior descending coronary artery �LAD�, and moderate stenosis of the distalpart of the of left main trunk �LMT� and the ostium of the obtuse marginal artery. We decided that the targetcoronary arteries were the LAD and LMT. We chose percutaneous transluminal coronary angioplasty
�PTCA� rather than coronary bypass surgery because he had a history of cerebral infarction . The distalLMT and ostial LAD stenosis were dilated with a 3.0�16 mm NIR stent �7-cell�. After stent implantation,there was aggravation of the left circumflex ostial stenosis. But performance of additional balloon dilatation
through the metallic structure of the NIR stent was di$cult due to balloon rupture. A cellular design of the
NIR stent was made from U joint to obtain flexibility and thicker C joint to obtain rigid sca#olding of the
vessel wall. We thought that this structure caused balloon rupture and di$cult to provisional T stenting with
a Multi-Link stent �3.0�15 mm�. After the procedure, stabilization of homodynamic was obtained and thepatient was weaned form circulatory support. PCI had been increasingly applied to LMT lesions with
variable long-term success. In this case, the 7-cell NIR stent proved di$cult to perform provisional T
stenting. Provisional T stenting for LMT stenosis may be a better strategy compared with systematic T
stenting, but we must be careful about the stent configuration.
Division of Cardiology, Department of Internal Medicine,
St.Marianna University School of Medicine, Kawasaki, Japan.
LMT ���������� ��� 395
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