Primary percutaneous coronary intervention for a left main bifurcation lesion without stenting using excimer laser
Masahiro Hada1, Tomoyo Sugiyama1, Yoshihisa Kanaji1
1Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, 4-1-1, Ohtsuno, Tsuchiura, Ibaraki 300-0028, Japan.
Insights
Excimer laser coronary angioplasty (ELCA) effectively reduced thrombus in a left main bifurcation lesion causing myocardial infarction. This approach, guided by optical coherence tomography (OCT), allowed intervention without stenting, leading to a positive outcome.
Area of Science:
- Interventional Cardiology
- Cardiovascular Imaging
- Acute Coronary Syndromes
Background:
- Optimal treatment for left main (LM) bifurcation lesions with significant thrombus is not well-defined.
- Excimer laser coronary angioplasty (ELCA) is a potential treatment for thrombotic lesions in acute coronary syndrome (ACS).
Background:
Optimal strategy for treating bifurcation lesions or lesions with large thrombus in left main disease remains elusive. Excimer laser coronary angioplasty (ELCA) is a therapeutic option for thrombotic lesions in acute coronary syndrome.
Case Summary:
A 68-year-old man with chest pain was transferred to our emergency department, and subsequently diagnosed as inferior ST-segment elevation myocardial infarction (STEMI). Emergent coronary angiography revealed a 75% stenosis in the left main trunk (LMT). Optical coherence tomography (OCT) showed massive thrombus at the distal LMT to the ostial left anterior descending artery (LAD) and left circumflex artery (LCx). ELCA was performed in the three directions from LMT to proximal LAD, proximal LCx, and obtuse marginal branch. OCT after ELCA showed reduction of thrombus and no apparent plaque rupture or calcification, implying that coronary thrombosis was caused by OCT-defined plaque erosion. Intracoronary electrocardiogram of the LCx showed ST-segment elevation which corresponded to inferior ST-segment elevation, whereas no intracoronary electrocardiogram ST-segment elevation was detected for LAD. Taking all of the data including angiographic appearance, OCT-derived residual lumen size and residual thrombus volume, and strategic options into consideration, we completed percutaneous coronary intervention without stent deployment. He has been free from any cardiac events thereafter for 8 months.
Discussion:
Optimal strategy of coronary intervention for bifurcation lesions, especially LMT bifurcations, remains elusive. ELCA may have a potential to safely reduce intracoronary thrombus in patients presenting with acute coronary syndrome with OCT guidance.
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