Stentless Treatment for a Left Main Quadrifurcation Lesion

Keywords: atherectomy, drug-coated balloon, intravascular ultrasound, left main coronary artery

A 69-year-old man underwent coronary intervention for stenosis in the left main (LM) quadrifurcation lesion with SYNTAX score 23 (SYNTAX II score: coronary intervention 27.5, bypass surgery 33.5) 1 week after primary stenting in the right coronary artery for non-ST-elevation myocardial infarction. The lesion consisted of the right-angle branched left anterior descending (LAD) artery, left circumflex (LCX) artery, and 2 ramus branches (RB1 and RB2), which demonstrated tight lesions in the proximal LAD and RB1 and a hazy image in the distal LM and LCX ostium on coronary angiography (Figures 1A and 1B; Video Series). Intravascular ultrasound (IVUS) showed eccentric plaque distribution from the LCX, opposite side to the myocardial site, which was consecutive in the distal LM and proximal LAD (Figure 1C; Video Series). Directional coronary atherectomy (DCA) was performed to debulk the eccentric plaque with a gradual increase in balloon pressure from 2 to 6 atm (Atherocut L), and the maximal percent plaque area was reduced from 77% to 47%. The minimal lumen area was enlarged to 8.57 mm². Adequate plaque debulking and lumen gain were obtained, and the lesion from the LM to the proximal LAD was treated with a drug-coated balloon (DCB) (SeQuent Please 3.5/20 mm). The RB1 lesion was also treated with a DCB (SeQuent Please 2.0/20 mm) after preparation with a scoring balloon (Scoreflex NC 2.25/10 mm). The complex LM quadrifurcation lesion was treated with a stentless procedure, which resulted in sufficient dilation in each branch (Figures 1D-1F; Video Series). Dual-antiplatelet therapy with 100 mg aspirin and 3.75 mg prasugrel was continued for 3 months, followed by aspirin alone. Any restenosis in follow-up coronary angiography (Video Series) or clinical event was not observed during the 1-year follow-up.

Due to the complex anatomy of the LM quadrifurcation, crossover stenting followed by proximal optimization and kissing balloon inflation have a risk of compromise on the side branches, and deployment of 2 or more stents has a risk of metal overlap at the ostium of the other branches. The stentless treatment with a DCB after sufficient plaque debulking with DCA is also ideal to avoid long-term dual antiplatelet therapy, especially in patients with high bleeding risk or those who plan to undergo the non-cardiac operation. Complete IVUS guidance to the direction of plaque debulking and monitoring the degree of debulking is crucial for safe and effective treatment. Although efficacy of this treatment at 1-year follow-up has been confirmed in a prospective multi-center registry,¹ randomized trials are still needed to clarify long-term safety and efficacy.

Affiliations and Disclosures

From the Department of Cardiology and Clinical Research Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 13, 2022.

Address for correspondence: Yoshinobu Murasato, MD, PhD, Department of Cardiology, National Hospital Organization, Kyushu Medical Center, 1-8-1, Jigyohama, Chuo, Fukuoka 810-8563, Japan.

Email: y.murasato@gmail.com

Reference

1. Kitani S, Igarashi Y, Tsuchikane E, et al. Efficacy of drug-coated balloon angioplasty after directional coronary atherectomy for coronary bifurcation lesions (DCA/DCB registry). Catheter Cardiovasc Interv. 2021;97(5):E614-E623. doi:10.1002/ccd.29185

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