Another approach, PCI with stenting, prevents immediate elastic recoil and thereby minimizes restenosis. Revascularization by Means of PCI and Stenting. In Patient 2, we intervened because PCI to the LAD led to acute occlusion of the first SPB and associated severe symptoms. In our Patient 1, we decided on POBA for 2 reasons: the vessel size precluded our using the smallest available DES (2.25 mm), and substituting a 2-mm bare-metal stent posed an unacceptable risk of restenosis. However, there is a risk of slow flow or no reflow, and it can be used only large-caliber SPBs. 18 To overcome this risk, a rotational atherectomy technique 7 can reportedly facilitate angioplasty by debulking the atheromatous plaque and minimizing the effect of elastic recoil. 12, 16 Furthermore, SPB atherosclerotic lesions are most often ostial, and treatment solely by means of POBA is associated with restenosis, 17 presumably secondary to elastic recoil. However, other investigators reported that intervention in the SPB can lead to acute vessel occlusion and complete heart block, either immediately or later. 1, 6–9, 12 In the largest relevant study (21 patients), 1 POBA of a large SPB had a 95% success rate. One approach is revascularization by means of POBA. The patient had severe chest pain, refractory to systemic analgesics and intracoronary vasodilators. The first SPB then became acutely occluded (TIMI 0 flow) ( Fig. Predilation with use of a 2 × 12-mm Emerge ® Monorail ® PTCA Dilatation Catheter (Boston Scientific Corporation Natick, Mass) preceded the deployment of a 3-mm DES. We engaged the LMCA with use of a 6F Judkins curved left 4 guide catheter (Cordis, a Johnson & Johnson company Fremont, Calif), then crossed the LAD lesion with a H i-T orque Balance Middleweight Universal Guide Wire (Abbott Vascular Santa Clara, Calif). This 2-mm vessel had 50% ostial stenosis ( Fig. Coronary angiograms revealed patent stents however, 90% stenosis of the mid LAD distal to a prior stent involved the takeoff of the first SPB. A 12-lead ECG showed ST-segment depression in the anterior leads. Her cardiac troponin I level was 1 ng/mL. Three years earlier, DESs had been deployed in her mid LAD and mid RCA. A 75-year-old woman with CAD presented with NSTEMI. Acutely Occluded First Septal Perforator Branch after LAD Intervention, Treated with POBA.

Timi ii flow