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Coronary Stenosis Evaluation - Supported with integrated FFR

Author: Lorenz Bott-Flügel , M.D.,
Department of Invasive Cardiology, Kreiskrankenhaus Erding, Germany

Patient history

A 72-year-old male with ongoing chest pain is being evaluated for coronary stenosis.
The patient has had a history of two myocardial infarctions in 1980 and 1994 and stents had been previously placed in the RCA and RCX. Due to a pathologic stress echocardiography, performed several weeks before, demonstrating moderate ischemic wall motion abnormalities in the anterior wall, a diagnostic left-heart catheterization was performed using radial approach, which is used in 80 % of the procedures.

Diagnosis

Good long-term results in the previously stented RCX and RCA; moderately calcified stenosis of the proximal and medial LAD (visually graded as being maximum 25-50 %).

Treatment

The FFR pressure wire was then introduced into the LAD and 140 μg/kg/min adenosine were given intravenously. After equilibration the FFR measurement did reveal a significiant stenosis (FFR = 0.67*).

Pullback of the pressure wire demonstrated a pressure jump just distal to the bifurcation with the 2nd diagonal branch, and along the proximal part of the LAD, which seemed rugged, thus maybe resembling an unstable plaque. After predilatation with a 3.5 mm balloon, a long drug-eluting stent (BioMatrix FlexTM 3.5 mm – 35 mm, Biosensors International) was implanted. Post placement, another FFR measurement showed a significant
improvement (FFR = 0.85).

Comments

Just from the angio it hardly looked like even a 50 % stenosis but the whole area seemed very rugged, like an unstable plaque (scene 1 on Artis). It is known that even a moderate stenosis in a major vessel, in this example the LAD, can constitute a hemodynamically relevant obstruction to antegrade blood flow. With the FFR values and the location of the lesion, it was possible to identify the culprit lesion and to successfully place a stent.
With the use of AXIOM Sensis FFR and Artis zee, Bott-Flügel is able to easily navigate the smart user interface, quickly obtain values to determine treatment, and have short fluoro run times. 

 

* An FFR < 0.75 indicates that the lesion is causing ischemia and should be considered for treatment (PCI).

 

Figure 1

Angiogram of the left anterior descending artery revealing only moderate vessel irregularities (arrows); both diagonal branches show 50 % stenosis at their origins.

Figure 2

FFR measurement of the LAD distal to the 2nd diagonal branch demonstrated a hemodynamically significant stenosis (FFR = 0.67).

Figure 3

Placement of a long drug-eluting stent (BioMatrix Flex™ 3.5 mm x 35 mm).

Figure 4

Final kissing-balloon maneuver with simultaneous PTCA of the LAD and the 2nd diagonal branch. No additional stent was placed in the diagonal branch.

Figure 5

Final result after stent implantation(LAO 45°, CAUD 20°).

Figure 6

Very good angiographic result after stent implantation.

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Date: Jun 01, 2012


Angiography - Case Studies

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