Simultaneous Kissing Stenting of Left Main Coronary Artery in AMI with Cardiogenic Shock

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Simultaneous Kissing Stenting of Left Main
Coronary Artery in AMI with Cardiogenic Shock

• Jing-Yu Hang
• Shanghai 6th Hospital
• Affiliated to Jiaotong University
• 2 August 2007

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Clinical Presentation

• 51 year female
• Sudden onset of chest pain and syncope 12 hrs
  before medical contact
• Past history PVD
• Risk factors smoking ,hypertension
  hypercholesterolemia, positive family history
• ECG ST elevation in anterior leads
• _at_ED VF arrest ,cardiogenic shock , intubated,
  transferred to cathlab

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Left Coronary Artery
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Left coronary artery
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Right coronary artery
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Left ventriculogram
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Cardiac catheterization

• LM distal 75 stenosis
• LAD ostial 75 stenosis, proximal subtotal
  occlusion
• LCX ostial 75 stenosis, mid LCX 90 stenosis
• RCA dominant vessel ,mild disease. LCA not well
  collateralized
• LV function Severely impaired
• Summary MVD distal LM disease LV?

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Consideration and strategy

• AMICardiogenic Shock lt36hrs
• Complete revascularization
• Distal LM prox. LADmid. LCX
• EuroScore 17 Logistic EuroScore 68
• Consider PCI
• Prompt , Simple technique,
• Adequate reconstruction
• Anatomy Sizable LCX
• Diameter of Main vessel 2/3 (SB1SB2)
• Technique Simultaneous Kissing Stent (SKS)

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Procedure

• IABP via RFA
• ReoPro IV
• 7F LFA approach
• Guiding 7F SL4
• Guidewire BMWs
• Sequential pre-dilatation of LAD- distal LM and
  mid-LCX to distal LM with 2.25x20 mm Sprinter
  balloon

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Pre-dilatation of LAD -LM
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Pre-dilatation of LAD -LM
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Pre-dilatation of LCX-LM
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Result of Pre-dilatation
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Procedure

• SKS 2.75x32mm Liberte stents (12/12 atm)
• Additional stenting LAD 2.5x8mm Liberte LCX
  2.5x10mm Tsunami .
• Post-dilatation 2.75x15mm Quantum balloons
  alternative dilatation (16atm) and final kissing
  balloon (12atm).
• Final result TIMI 3 flow in both SB, Spiral
  dissection in LCX (under stent)

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Simultaneous kissing stenting 2.75x32mm Liberte
(12 atm)
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Result after SKS
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Additional stenting in LAD Liberte 2.5x8mm
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Additional stenting in LCX Tsunami 2.5x10mm
Spiral dissection
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Post-dilatation--Alternative dilatation and
final kissing2.75x15mm Quantum
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Final result
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Outcome and Follow-up

• Discharged 2 weeks later
• Chronic heart failure
• 4 months angiogram follow-up
• Patent LM, LAD and LCX stents.
• LCX dissection healed.

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Advantage of SKS

• Simple technique, No rewiring or further kissing
  balloon required
• Treat multiple diseased segment in one pass
• The anatomy of LMS bifurcation lesions usually
  follows the pattern of one large vessel giving
  rise to two medium sized vessels
• SKS does not involve any distortion of stent
  architecture

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Disadvantages of SKS

• 1.New artificial septum fashioned from double
  layer of stent
• 2.Potential for thrombus accumulation
• 3.Difficult if there is a large ramus
• 4.If either of the branch arise at 90 angle
• 5.Extra challenge posed by recatheterization

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Comments
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Technique of SKS
7/8F Guiding
Kissing at Medium pressure
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Technique of SKS
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Cardiac catheterization
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• 30 patients
• SKS with PES
• 6mos Angiographic follow-up
• TLR 6.8
• Animal model 90days endothelium

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CCI 2005
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• Complete? Revascularization ? Yes AMICS
• PCI or CABG? PCI high surgical risk
• Strategy to treat LM Prompt , Simple technique
  
• Adequate reconstruction

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Left coronary artery