Case presentation

A 55-year-old woman with diabetes and hypertension presented to the emergency room with sudden onset of chest pain. She had undergone catheterization 5 years earlier, at which time she was found to have nonobstructive coronary disease involving the left anterior descending artery. Initial and subsequent electrocardiograms and serial biomarkers remained normal with no evidence of acute infarction. Diagnosed with unstable angina, she was treated with aspirin, clopidogrel, and low-molecular-weight heparin, and was referred for cardiac catheterization the next day.

Cardiac catheterization

Cardiac catheterization revealed a complex 90% stenosis of the left anterior descending (LAD) artery at the bifurcation of a first diagonal branch (D1). The stenosis extended proximal and distal to the D1 branch; in addition, the D1 branch had an 80% stenosis at the ostium (Figures 2-1, 2-2 and Videos 2-1, 2-2, 2-3). No other significant lesions were observed (Figure 2-3), and left ventricular function was preserved.

FIGURE 2-1 This is a right anterior oblique angiogram with caudal angulation of the left coronary artery demonstrating a complex lesion in the proximal segment of the left anterior descending artery involving a large diagonal side branch (arrow).

FIGURE 2-2 This is a left anterior oblique view with caudal angulation showing the complex bifurcation disease. This view may be helpful to determine if there is disease involving the ostium of a diagonal side branch, as other views sometimes overlap the diagonal ostium.

FIGURE 2-3 The right coronary artery was normal.

The physician chose to treat the artery percutaneously. Using bivalirudin as the procedural anticoagulant, a 6F Judkins left guide coronary catheter with 4 cm curve (JL4) was used to engage the left coronary artery. A 180 cm long, 0.014” floppy-tipped guidewire was advanced into the LAD and the lesion directly stented using a 2.5 mm diameter, 25 mm long sirolimus-eluting stent. This resulted in an excellent angiographic result in the LAD (Figure 2-4 and Video 2-4). A second floppy-tipped guidewire was positioned in the first diagonal branch, passing through the LAD stent. The diagonal stenosis was first dilated with a 2.5 mm diameter by 15 mm long compliant balloon (Figure 2-5) but this produced a suboptimal result at the ostium (Figure 2-6 and Video 2-5). Thus, a 2.5 mm diameter by 18 mm long sirolimus-eluting stent was positioned at the ostium and deployed (Figure 2-7). The final angiographic result is shown in Figure 2-8 and Video 2-6.

FIGURE 2-4 After stenting the main vessel, there remains significant narrowing in the diagonal side branch (arrow).

FIGURE 2-5 A guidewire was placed through the stent struts into the diagonal branch and balloon angioplasty of the diagonal was performed.