Co-registration of long lesions: choosing the best management.
Authors: Luis Raposo, Mariana Paiva, Sérgio Madeira – Hospital de Santa Cruz, Lisboa, Portugal
Patient ID and referral
68 years old man referred due to typical angina (CCS 2-3) and a positive stress test (chest pain without EKG changes).
Relevant prior medical history
Ischemic stroke (posterior left cerebral artery), hypertension, dyslipidemia, and epilepsy.
No known diabetes.
Medications
Aspirin 100 mg id, clopidogrel 75 mg id, losartan 50 mg id, rosuvastatin 20 mg id, transderminc nitroglicerin 5mg/24h, bisoprolol 2.5 mg, valproic acid 300 mg bid.
Case Description
The patient was referred in a stable setting.
Left ventricle function was normal, and there was no evidence of additional structural abnormalities.
The coronary angiogram was relevant for diffuse involvement of the proximal and mid LAD with two focal stenosis involving the origin of two diagonal branches. Other than a mild lesion on the mid-RCA, no obstructive disease could be demonstrated in other locations (Video 1).
Image 1: Baseline angiogram showing difuse disease of the proximal and mid LAD (cranial projection).
Invasive functional assessment with an OMNIWire® pressure guidewire and using the SyncVision® software – to allow for co-registration – was performed to guide therapy (spot PCI vs PCI with long stenting extending from the proximal to the distal LAD vs CABG).
The pullback corresgistration curve showed two focal gradients, with the most important at the level of the more distal lesion (Image 2 and image 3). The virtual PCI of this lesion, estimated a final IFR of 0.93 (Image 4). In order to avoid compromising future treatment options (give patients age, in case of disease progression) e proceeded with focal PCI with a paclitaxel drug eluting balloon (Image 5).
Image 2: Baseline iFR distal do to the mid-LAD lesion.
Image 3: Baseline Pd/Pa distal to the mid-LAD lesion.
Image 4: iFR and angiography and angiography co-registration of the LAD showing higher pressure lose in the more distal lesion
Image 5: Drug-eluting balloon inflation at the mid LAD lesion.
The lesion was prepared with a 2.5/10 mm non-compliant balloon, followed by plaque modification with a 2.5/10 mm cutting-balloon and, finally a 2.5/18 mm paclitaxel-eluting balloon was applied. A type B dissection was identified (video 6), without accompanying ST segment abnormalities, chest-pain, or angiographic progression within 10 minutes. This was considered an acceptable result.
Image 6: Final angiogram of the LAD in the cranial projection
Image 7: Final functional result (iFR) of the LAD.
The final functional assessment showed an iFR of 0.92, as predicted by the baseline virtual PCI (0.93).
The patient recovery was uneventful, and he remained pain-free and with a negative non-invasive assessment of ischemia (perfusion MRI) at the 3-months.
Comments
This case further illustrates how co-registration using non-hyperemic indexes may efficiently assist individualized treatment plans. Randomized trials are ongoing, which will clarify its potential clinical implications in routine practice.
