Unprotected LM stem PCI

By: AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC,Shahabuddin Talukder, MBBS, D. Card, FCPS;

Submitted: 05/07/2012

AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC,Shahabuddin Talukder, MBBS, D. Card, FCPS;

Dept of Invasive and Interventional Cardiology, Apollo Hospitals Dhaka.

Apollo Heart Center of Apollo Hospitals Dhaka, Bangladesh

Clinical History
Mr. AK/55M, admitted for angiogram for ongoing exertional dyspnoea. He had H/o Inf. MI (silent), Cardiogenic shock in the recent past for which treated elsewhere. His CAD Risk factors were HTN, Dyslipidemia, Ex-smoker.

LMCA: 70% eccentric plaque at ostium (Fig.1). LAD: 70-80% mid segment lesion (Fig. 2) LCX: Normal RCA: 90% long mid lesion (Fig.3)

LCA was engaged with the EBU-3.0(7F) guide catheter. Galeo floppy wire was taken to distal LAD. Ballooning of mid-LAD lesion was done by a Avita 2 x 15 mm balloon (Fig 4). Then, mid-LAD plaque was stented with a 3.0 x 23 mm Cypher stent at 16ATM (Fig 5 and Fig 6) LM Stem: After Stent positioning into the ostial LM lesion (Fig 7), a 3.5 x 13 mm Cypher stent deployed at 16-18 ATM (Fig 8). Further, ballooning was done by a 4x 10mm Balloon. Cine shows well deployed stent with TIMI-III distal runoff (Fig 9). After 48 hrs, PCI of RCA was carried out. Ballooning to RCA culprit lesion by a 2x 15 mm balloon (Fig 10). RCA: Stenting of RCA lesion by deploying a 3.0 x 33 mm Cypher stent at 14-16 ATM (Fig 11). Cine angio shows well deployed stent with TIMI-III distal run-off. Patient discharged in a stable condition and being followed-up at cardiac OPD. Remain asymptomatic 12 months after PCI.

Unprotected LM stem PCI is a high risk complex interventional procedure. Interventionist skill and available hard wire support are necessary. CABG would be the preferred option in this type of lesion specially LM stem with mLAD and mRCA lesion. Staged PCI of LM stem and other territory lesion is always safe . After Successful PCI of Ostial LM and mid LAD and RCA lesion, clinically patient remains asymptomatic 1yr after PCI.

Since, the evolution of first LM stem PCI in 1978 by Gruentzig, several Multicenter trial has proven potential clinical benefits of PCI of both protected and unprotected LM stem over CABG in inoperable patients with co-morbid condition and thereby increase survival rate. In stable case and specially in young patient with angiographic LM stem disease, PCI will not only defer the untoward effects of CABG but, it can keep a window of future surgery if needed. As in this subcontinent and specially in Bangladesh, we found that many of the young patient having LM stem disease at early 30 to yrs of age and associated risk factors were Smoking, genetic inheritance, DM, HTN.

Conflict(s) of Interest













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