Treatment of LAD & First Diagonal Branch

Overview

Dr. Jeff Chambers treated a calcified left anterior descending (LAD) and first diagonal branch using orbital atherectomy.

Patient History

The patient is a 77-year-old male who had stenting of a severe lesion in the proximal right coronary artery (RCA) one month prior for unstable angina. He had a severe calcified left anterior descending (LAD) artery at that time, which was managed medically. He continued to have had chest pressure on double antianginal therapy and an Adenosine Cardiolite demonstrated anterior ischemia. The patient’s medical history included hypertension, hyperlipidemia, borderline diabetesand hypothyroidism. He was referred for intervention of the LAD and first diagonal branch.

Treatment Summary

Angiography and intravascular ultrasound (IVUS) demonstrated severe calcification on both sides of the arterial wall. The LAD was severely diseased in the mid-LAD, as was the ostium and proximal portion of the diagonal branch.

Given the amount of severe calcification, it was decided to treat the lesion with orbital atherectomy. The universal wire in place for the IVUS was replaced with a ViperWire Advance® Coronary Guide Wire. Orbital atherectomy was performed with two passes on low speed (80 kRPM) and three passes on high speed (120 kRPM).

Using a universal guide wire, the diagonal was pre-dilated with a 2.5 x 12 balloon. A 2.5 x 20 stent was then placed, which was deployed at 12 atm. Both the proximal ostial lesion and the mid lesion and had a good angiographic result. It was determined that the LAD could be directly stented as the IVUS showed modified plaque and vessel compliance a reduction in the arc of calcium. A 3.5 x 30mm stent was placed. The vessel was post-dilated with a 3.75 balloon at 16 atm. A universal wire was then placed in the diagonal and the procedure was completed with a kissing balloon angioplasty using a 2.25 x 12 NC balloon in the first diagonal and a 3.5 x 12 NC balloon in the LAD, both balloons at 12 atm. Excellent angiographic results were achieved.

Key Takeaways

A calculated approach to device selection is necessary in the treatment of complex coronary disease

Intravascular imaging was essential to assess the lesion, which resulted in the determination that atherectomy was necessary for adequate vessel preparation, enabling successful stent deployment.

Successful revascularization of the LAD and diagonal branch were accomplished using the Diamondback 360® Coronary Orbital Atherectomy System.


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