Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Prakash Sanzgiri,Srinivas Kudva,Charan Reddy Kv,Rohan Thanedar

doi:10.33805/2639.6807.129

Abstract

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

Highlights

Case ReportsOstial Left Anterior Descending Coronary MVD-Multi-Vessel Disease (Artery) (LAD) lesions were for long regarded as those clinical subset that are unsuitable for coronary stenting
Ostial Left Anterior Descending Coronary Artery (LAD) lesions were for long regarded as those clinical subset that are unsuitable for coronary stenting
Simple ostial LAD lesions can be managed with focal stenting only

Summary

Introduction

Ostial Left Anterior Descending Coronary Artery (LAD) lesions were for long regarded as those clinical subset that are unsuitable for coronary stenting. The lesion may appear localised to ostium of LAD, but in most cases, the plaque extends into the LMCA or Left circumflex (LCx) artery. Coronary Angiography (CAG) showed total thrombotic occlusion of LAD from ostium with mild nonocclusive plaques in mid LMCA and proximal segment of a nondominant left circumflex artery (Figure 1a, 1b). Coronary angiography performed showed patent LAD stent, but LCx showed a sluggish flow with Thrombolysis in Myocardial Infarction (TIMI-2) probably due to plaque shift (Figure 2a-c). Coronary angiography showed total thrombotic occlusion of ostial LAD, minor plaques in ostium of a large dominant LCx (Figure 4a, 4b). Repeat coronary angiography showed 90% ostial circumflex stenosis, with mild increase in LMCA plaque lesion when compared to the previous CAG. The stent in the LAD was patent with TIMI-3 flow (Figure 6a, 6b)

Findings

Discussion

Conclusion