Flexibility of the COMBO Dual Therapy Stent

Transcription

1 TM CaseSpotlight Flexibility of the COMBO Dual Therapy Stent Doctor Peter den Heijer is an of the Catheterization Laboratory at the Department of Cardiology of the Amphia Ziekenhuis, Breda, The Netherlands. Dr. Peter den Heijer The patient is a 65 year old male with ischemic cardiomyopathy and a history of smoking and hypercholesterolemia. MRI showed viability in the posterolateral myocardial region and he was accepted for PCI of a single lesion in a large marginal branch. The pre-procedural angiogram showed a highly calcified, diffusely diseased, circumflex artery with extreme proximal tortuosity and a >90 origin from the left main, making the PCI a challenge for any coronary stent system (see Figure I). A 6F extra backup guiding catheter with a guiding catheter extender was used for extra support. The circumflex artery margo obtusis (CX-MO) was cannulated with a highly flexible guidewire (see Figure II), and the lesion predilated with a 2.0 x 10 mm SapphireTM II Coronary Dilatation Catheter. After that, a 2.5 x 13 mm COMBO Dual Therapy Stent was inserted. Fluoroscopy clearly showed the flexibility of this dual therapy stent, resulting in superior trackability and deliverability. The COMBO Stent was deployed at 18 atm, giving an excellent angiographic result (see Figure III). I was extremely pleased and somewhat surprised by the flexibility of the Combo Stent in such tortuous anatomy, said Dr. Den Heijer. Fig. I: Pre-procedure Fig. II: Tracking through tortuous circumflex 2013 OrbusNeich. All rights reserved. Not available for sale in the USA. #G Rev01 Fig. III: Post procedure

2 COMBO Dual Therapy Stents in a severely calcified RCA Doctor Simon Eccleshall is an of the Catheterisation Laboratory at the Department of Cardiology at the Norfolk and Norwich University Hospital, Norwich, United Kingdom. Dr. Simon Eccleshall, MB, ChB (Birm), MRCP The patient is an 84 year old female with anaemia and renal issues. The LAD was blocked and the left side was being filled from collaterals from the RCA. However, the diagnostic pre-procedural angiogram had shown extensive but diffuse calcium throughout the length of the RCA. The decision was made to gradually pre-dilate the RCA before stenting. Upon IVUS, the RCA was shown to have eccentric calcium with the exception of the ostium that showed a tiny napkin ring of calcium (see Figure I). A 3.0 x 15 mm Scoreflex Dual Wire Balloon was used first to prepare the ostium of the RCA and a 4.0 x 15 mm Scoreflex was then used at the ostium and for the two calcified lesions in the mid vessel. After that three COMBO Dual Therapy Stents (4.0 x 33 mm, 4.0 x 23 mm and a 4.0 x 9.0 mm) were successfully implanted in the RCA and post dilated with two 4.5 mm Sapphire NC Coronary Dilatation Catheters (12 and 18 mm). The outcome, viewed with IVUS, showed an excellent result (see Figure II). The final cross filling image shows how well the collaterals are filling the left side (see Figure III). "The COMBO Stent appeared to be a great stent for this very difficult case with a high risk of bleeding," said Dr. Eccleshall. Fig. I: Pre-procedure Fig. II: Post procedure Fig. III: Cross filling 2013 OrbusNeich. All rights reserved. Not available for sale in the USA. #G Rev01

3 COMBO Dual Therapy Stents in an ACS patient with bleeding complications Doctor Michael Pitt is the Clinical Director for Cardiology and Doctor Colin Chue is an ST4 Registrar in Cardiology at the Department of Cardiology at Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom. Dr. Michael Pitt, MRCP, MBChB, FRCP Dr. Colin Chue ST4 in Cardiology, MBChB(Hons), MRCP(UK), PhD The patient is a 73 year old male with hypertension and hyperlipidaemia who was admitted with a non-st elevation myocardial infarction and troponin rise from 98 to ng/l. He was in atrial fibrillation with left bundle branch block and was commenced on amiodarone and digoxin. The patient was also being considered for warfarin therapy. An angiogram performed three months previously for exertional angina demonstrated significant 3 vessel coronary artery disease and a myocardial perfusion scan demonstrated reversible ischemia in the inferior territory. Repeat angiography during this admission confirmed worsening disease in the mid vessel of a dominant right coronary artery (see Figure I) and a severe bifurcation lesion affecting the LAD and first diagonal (see Figure II). The circumflex artery was occluded in the mid vessel as noted previously. The RCA was rebuilt with three COMBO Dual Therapy Stents (a 2.75 x 23mm in the PLV branch, a 3.0 x 9mm before the origin of the PDA and a 4.0 x 28mm in the mid vessel; see Figure III). The LAD bifurcation lesion was treated with two 3.0 x 23mm COMBO Stents deployed in a Cullotte formation and post dilated with two 3.25mm non-compliant balloons in a kissing formation (see Figure IV). An excellent final angiographic result was achieved (see Figure V). "COMBO is a great stent to address the needs where the use of dual antiplatelet therapy are of concern," said Dr. Pitt. Fig. I: Pre-procedure RCA Fig. II: Pre-procedure LAD Fig. III: Post procedure RCA Fig. IV: Post procedure LAD Fig. V: Post procedure Cx 2013 OrbusNeich. All rights reserved. Not available for sale in the USA. #G Rev01

4 Complex Lesion Treated with the COMBO Stent Shows Excellent Results at 6 Month Angiographic Follow Up Professor Robbert de Winter is at the Heart Center of the Academic Medical Center, Amsterdam, The Netherlands. Prof. Dr. R.J. De Winter The patient is a 79 year old male with unstable angina and high risk factors including diabetes, family history of atherosclerotic disease and smoking habit. At the referring hospital, angiography was conducted which revealed a severely calcified subtotal stenosis at the proximal RCA and a second lesion at the proximal LAD. The RCA lesion was determined to be the culprit (Figure 1a) and was treated at our center. Figure 1a: Pre-procedure The heavily calcified lesion was pre-dilated with a 2.5 mm balloon at 10 atm. After pre-dilatation, a 3.5 x 13 mm COMBO Dual Therapy Stent was successfully implanted. The remarkable trackability and deliverability of the COMBO Stent allowed an accurate and uncomplicated placement of the stent with excellent result (Figure 1b). Six months later, the patient was re-admitted with stable angina and angiography confirmed progressive disease in the LAD. Meanwhile, the COMBO Stent previously implanted in the RCA remained patent (Figure 1c). With calibration using FFR showed a fractional flow reserve of 0.64 in the LAD (Figure 2a), coronary intervention was performed and the LAD lesion was stented with a 2.5 x 18 mm COMBO Dual Therapy Stent at 14 atm (Figure 2b). Figure 1b: Post procedure Figure 1c: 6 Month follow up Figure 2a: Pre-procedure Figure 2b: Post procedure 2014 OrbusNeich. All rights reserved. Not available for sale in the USA. #G Rev01

5 Bifurcation Lesion Treated with COMBO Stents Doctor Ian Menown is Director of Interventional Cardiology at the Craigavon Cardiac Centre, Southern Trust, Northern Ireland. Dr. I.B.A. Menown The patient is a 63 year old man with previous myocardial infarction. He was referred for treatment of a bifurcation lesion (0,1,1 Medina classification) at a large Obtuse Marginal (OM) dominant AVCx bifurcation (Figure 1). The patient has a history of hyperlipidemia and hypertension with a left ventricular ejection fraction of 60%. Upon good anchorage of a 6F radial guiding catheter at the left ostium, two guidewires were positioned at the distal OMCx and at the distal dominant AVCx branches, followed by pre-dilatation of both arteries sequentially using a 3.0 x 15 mm balloon prior to stenting. A 3.5 x 18 mm COMBO Stent was first deployed from the mid LCX into the OMCx branch (Figure 2), followed by the deployment of a second 3.5 x 18 mm COMBO Stent from the mid LCX to the AVCx using the Culotte stenting technique (Figure 3). The guidewires were repositioned into both stents, followed by post dilatation of the stents, by a kissing balloon technique using two 3.5 x 15 mm noncompliant balloons (Figure 4). An excellent angiographic result was obtained (Figure 5) and the patient remained symptom free on follow up. Figure 1: Pre-procedure Figure 2: COMBO Stent 1 Figure 3: COMBO Stent 2 Figure 4: Kissing Balloons Figure 5: Post procedure 2014 OrbusNeich. All rights reserved. Not available for sale in the USA. #G Rev01