Case 43: LCX OSTEA- The " Achilles heel" of LM stenting techniques.

Added: 2026-05-07

[00:00:00]This is a 60 5 plus executive who's had an angioplasty to the right for acute inferior in 2000 2, then again in 2014, and now again presented a few days back with an occluded RCA just at the top where this was uh occluded just before the stent. So, we put in a stent about a week back, and his LV is fine.

[00:00:29]So, now we bring him back to uh check because we had not done an NC here. So, he had left main disease as well. So, the aim was to bring him back, and when we do the left main because he had refused surgery to to do the left main and then check his and we'll probably do the NC then. So, this is his left main disease.

[00:00:52]Uh as you can see, it's uh pretty severe. This was not there in 2014. So, it's around 60 50 to 60% and you can see that the ostium of the uh is pretty diseased. We not when we're doing the acute MI uh inferior wall in another hospital, we did not look at it this too closely, but now this is quite severe and quite clear that it we would need a two-stent strategy uh for this left main. Uh but this is the uh this is the case. So, we did the NC balloon dilatation, and uh this was the final result.

[00:01:34]Uh we dilated this by 3.75.

[00:01:37]There is uh residual disease uh in these stents. These were put in in 2014, and uh So, but otherwise, you know, he's uh continuing to smoke uh and a strong family history. Uh so, he used to have risk factor modification. So, this was the right.

[00:02:04]show you some steps in the DK crush that are important. So, we did an intravascular ultrasound, and I'll show you the luminal area uh later. And we ballooned this, and you can see that the circumflex uh has a significant recoil. So, we went ahead after 2 mm balloon. We should have maybe prepared this better, but you can see after this the stent open doesn't open up fully. And this is a 4-mm 4 by 8-mm stent. And once you crush it, you can see the amount of residual recoil uh which is very significant. And this is a probably an error that one should avoid by doing a cutting or ideal here because the rota will not work. It's a large vessel. This is a 4-mm stent, and you can see that it's not opened up.

[00:02:56]Uh so, now the thing to do is to keep a balloon so that you don't uh stop the access to the obstructed LED, and then you start sequentially ballooning with a high pressure. So, sequentially do this before you crush it. So, this is again uh this now opens up a 3.5 and uh so, 3.5 at a very high pressure about 20% residual again like this.

[00:03:26]And uh so, this is slightly better.

[00:03:31]Slightly better, but uh not ideal.

[00:03:34]And when you look at it in another view just before you're planning to crush, you can see that this is uh this is still quite significantly narrowed. So, now what to do? Do you do an IVL now? Try and open up the calcium or the I think uh yes, you can. But then another view is to open it up with a even a higher pressure. This is now 3.75.

[00:04:05]And this is what we did.

[00:04:08]And uh this does open up the significant recoil later, but then uh you know, we sometimes you have to tolerate certain So, then then then it becomes pretty simple. You have to put in, crush it, and uh crush the stent, and uh keep a wire in there. So, still it's not ideal, but you bought it.

[00:04:36]And you recross distally. Try and recross distally.

[00:04:41]And then again now after a lot of uh 1 2 1 high pressure inflations, you can see that the final result uh is not bad.

[00:04:53]So, you can see this is the final result, and we managed to open up this and the left main. So, the the the lesson is that try and do an optimization here, but if you don't, then don't put a stent across unless you can at least get enough lumen here. And then once you've crossed it and crushed it and the the double kiss crush, try and put another balloon of 3.75 4 mm NC that we did and managed to open this up so that give way. So, just a lesson here that the ostial circumflex is is very difficult to handle something. This is the final You got our stent taken, and this is about 4.5 uh and uh This is 4.5, and there's a 4-mm stent according to the IVUS, and this is 375 and tapers down to the normal LED, which is fine.