Unprotected Left Main


Getu Assefa, MD

Patient History

A 76-year-old male presented with complaints of angina at rest, severe dyspnea, and non-ST-elevation myocardial infarction (NSTEMI). He had a known history of coronary artery disease (CAD) and had undergone proximal left circumflex (LCx) stent placement in 2009. Cardiac history also included paroxysmal atrial fibrillation, hypertension, and low ejection fraction. The patient had a complex pulmonary history including non-small cell lung cancer with left upper lobe lobectomy in 1998 (in remission), emphysema, 30-pack-year history of cigarette abuse and a requirement for oxygen at home. He also suffered from chronic kidney disease and was unable to walk without the use of a walker.

Diagnostic angiogram revealed significant obstructive CAD involving 80% mid to distal left main (LM), 90% ostial and proximal left anterior descending (LAD) and 80% ostial and LCx arteries.

The patient was referred to two different institutions and surgical teams for coronary artery bypass graft (CABG) surgery. Both surgical teams declined to do the surgery and considered the patient to be a high surgical risk due to his advanced emphysema, status post left upper lobe lobectomy, kidney disease and low ejection fraction*, but considered him an appropriate candidate for atherectomy.

Treatment Summary

Left femoral artery access was achieved for placement of a percutaneous, catheter-based heart pump for hemodynamic support. Right femoral artery access was achieved with an 8 Fr. sheath. A mini-stick technique was used to obtain access in both arteries. Unfractionated heparin was used for anticoagulation and a therapeutic activated clotting time (ACT) was obtained.

The LM was engaged using an extra backup (EBU) 3.5 8 Fr. guide catheter. A 300 cm workhorse coronary guide wire was advanced into the LAD and then exchanged for a ViperWire Advance® Coronary Guide Wire. Calcium modification of the lesions was achieved with orbital atherectomy. The Diamondback 360® Coronary Orbital Atherectomy System (OAS) 1.25 mm Classic Crown was passed over the LM and LAD lesions a total of 6 times at low speed with good results.

A 3.5 mm x 20 mm compliant balloon was then advanced into the LM-LAD and inflated to 6 atm with no waist. The LCx was then crossed using a 300 cm workhorse wire followed by kissing balloon angioplasty of the LM-LAD and LCx with a 3.5 mm x 20 mm balloon at 8 atm and a 2.5 mm x 12 mm balloon at 12 atm respectively. Double kissing crush technique of the LM-LAD and LCx was performed with a 4.0 x 23 mm DES at 12 atm and a 3.5 x 28 mm drug eluting stent at 16 atm respectively. Final kissing balloon inflation was performed with a 3.5 x 15 mm non-compliant balloon in the LM to LAD and 3.5 x 15 mm non-compliant balloon in the LM to LCx both inflated to 12 atm. Lastly, a 4.0 x 15 mm non-compliant balloon in the LM was inflated to 16 atm.

Physician noted excellent results in the final angiogram. The percutaneous, catheter-based heart pump was weaned and removed in the cath lab. The sheath was removed and vascular closure systems were used to achieve hemostasis in both the left and right femoral arteries. There were no complications associated with the PCI or during follow-up.

Two weeks after the PCI, the patient was seen in the office for follow-up. The patient’s chest pain had resolved and dyspnea improved. New York Heart Association (NYHA) Functional Classification decreased from Class III (moderate)/ Class IV (severe) pre-PCI to Class II (mild) post-PCI. The patient’s ability to walk unassisted improved. He no longer needed to use a walker.

Key Takeaways

  • Successful PCI was achieved using Orbital Atherectomy to modify the severely calcified lesions and to allow for successful facilitation of multiple stents.
  • High-risk PCI can be safely performed with appropriate hemodynamic support and Orbital Atherectomy to help optimize stent expansion and PCI outcomes.
  • Orbital Atherectomy allowed the physician the ability to treat multiple vessel sizes with a single crown.

*Precaution: Ejection fractions less than 25% have not been studied, use with low ejection fractions may require additional precautions due to compromised heart function.

Results may vary.

Pre & Post Procedure Images


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