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Archive for the ‘Left main stenting -Tips and tricks’ Category

Medina classification  is the most popular angiographic classification  of bifurcation lesions based on the presence or absence lesions at the three levels  of branching  (0,0,0 ) to (1,1,1). The popularity of this scheme is essentially due to its simplicity.

It can further be subdivided according to angle and size .Though there are three angles possible it is the angle of LM with LCX that matters most.

T shaped  left main. Angle of LM-LCX is around 90 Degrees

Y shaped left main. Angle of LM- LCX is > 120 Degrees

Three types of Y according to size of branch vessel size.

Y1 Large left main divided two equal LAD, LCX.

Y2 Left main and one of its branches are equal

Y3 All three are equal diameter.

Here is a series of  lectures on left main (Probably the best I guess  !)  from Dr.Boris Varshisky ,Hadassah University hospital  Jeruselam.He critically discusses about the   nuances of left main disease from pathology, technical and therapeutic considerations.

Spend some time on these videos , you should be able to learn about

  • Distribution of left main disease
  • The complexities in defining the true shapes of of left main ostia .(Ostial sharing between LCX and LAD ?)
  • Lesion based strategy
  • Carinal shift vs plaque shift
  • Stent sizing in Y 3 left main

and much , much  more !

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Fractional flow reserve(FFR) is an  Intra coronary hemodynamic  parameter  promoted recently to assess the physiological impact of a coronary lesion . Though it sounds logically attractive the concept  is sailing in rough seas  .I am afraid FFR is drowning  a fairly useful tool of IVUS  along with it  !

Read this large study on FFR (JAMA June 2014) .It seems to suggest  FFR is a costly and unnecessary accessory in cath lab

Image

Critical thoughts on FFR

It adds time , money , and procedural risk*  to any given patient .The only possible use is to reduce the proliferating stent usage !But the  irony  is complete as we do our daily business in  modern cath suits .To negate  one indulgence we need to  need to indulge  in  another ! (Junk begets Junk !)

It reflects lack of courage on the part of cardiologists to advice medical management even in obvious low risk lesions !

It is unfortunate ,we need a scientific or  a pseudo scientific tool to lift up our sagging medical intellect !

 

* crossing  delicate and often complex lesions  without any major purpose is bad wisdom !
(more…)

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Left main ostial lesion remains a  challenging task .A new stent design is  proposed here.

The lesion

Left main  ostial  stenting lesion003

The hardware 

left main ostial coronary stent drsvenkatesan

The technique

Left main  ostial  stenting lesion002

Final message

This thought came  when I  recently encountered a patient with a left main ostial  stent which was projecting well into aortic root .It is an open access patency ,whoever is capable of converting this idea  to a clinically applicable technique is welcome to proceed !

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