Case 168: Manual of PCI - CT and FFRangio guided PCI

A patient presented with exertional dyspnea and was found to have anterior ischemia on nuclear stress testing. Coronary CT angiography showed a severe lesion in the proximal LAD with an area of circumferential calcification. Estimated stent length was 28 mm with 2.8 mm distal reference and 3.3 mm proximal reference diameter. These findings were confirmed on coronary angiography.
After predilatation a 3.0x30 mm stent was deployed from the left main into the mid LAD, jailing the circumflex and the first diagonal. FFR angio of the diagonal was 0.89. IVUS showed under-expansion of the distal left main stent that was successfully treated with intravascular lithotripsy. The ostium of the circumflex was “pinched”, hence kissing balloon inflation was done with a 3.0 mm balloon in the LAD and a 3.5 mm balloon in the circumflex with an excellent result. FFRangio of the circumflex was 0.93. The patient had an uneventful recovery and his symptoms resolved.

[@tom11298]

Coronary CT has excellent value for pre-planing, for example guide selection, composition of the stenosis and reference distal diameter, it is great tool to shorten the procedure and anticipate

[@shangz0216]

Thanks for sharing.

[@mahmoud_elrayes]

Perfect case. If you perform IVUS of LCX ostium after kissing and found MLA of ostial LCX below 4.0 mm2 despite of negative FFR( discrepancy between FFR and IVUS results) , will you proceed to further intervention of LCX or not? Thanks.

[@manosbrilakis]

Great question: I am not sure, it would depend on the actual area, but I would probably have treated the circumflex given its large size.

[@wilzboyz]

Should’ve done high psi NC, cutter or IVL prior to stent deployment. Followed by IVUS to confirm calcium fracture. W that circumferential Ca on CT no reason to deploy stent before adequate vessel prep. Nice case

[@manosbrilakis]

Good point!

[@ahmettemiz2528]

Nice case as always . When I started to watch video I thought that 3 .0 mm stent may be undersized according to the Cx size . Can we safely rely on the CT findings for sizing ?

[@manosbrilakis]

Good point - CT does indeed undersize a little compared with IVUS. The key factor is nitroglycerine prior to CCTA: if the patient receives a good dose (usually 0.8 mg) of nitroglycerine lumen measurements are more accurate.

[@ahmettemiz2528]

@@manosbrilakis thank you sir. I cant describe how you improved my knowledge and viewpoint

[@dianecalabrese228]

Great explanation- thank you, Dr Brilakis ! I was not aware you were measuring the distance of the takeoff of the artery to the opposing aortic wall for choosing guide curve size …..

[@amribrahim3595]

Nice case as usual
Why we didn’t preform FFR to the LCX before kissing balloon ?

[@manosbrilakis]

Good point - we could have, but angiographically it looked quite stenotic.