Follow-up optical coherence tomography to evaluate circumflex ostium after fenestration of left main Papyrus covered stent: a case report

Background: Left main (LM) perforations necessitating a covered stent risk sacrificing the side branch. The lost side branch can be promptly recovered by fenestration of the covered stent, using a stiff wire. However, it is unclear whether subsequent balloon angioplasty of the recovered side branch ostium is sufficient to preserve side branch patency. We report the longer-term patency of the circumflex (LCx) ostium after LM covered stenting.

Case summary: A 78-year-old lady, with stable angina, presented for elective angiography. Percutaneous coronary intervention of the left anterior descending (LAD) artery to LM was complicated by a distal LM perforation. A covered stent across the LM sealed the perforation but resulted in acute occlusion of the LCx. The LCx was rescued by fenestration of the covered stent with a stiff wire, followed by balloon angioplasty to the LCx ostium. At follow-up, the angina had resolved. However, follow-up angiography demonstrated a new severe stenosis at the LCx ostium, with remnants of the polyurethane membrane seen protruding into the LCx ostium on optical coherence tomography. Therefore, the LCx ostium was stented, using the reverse Culotte technique.

Conclusion: This case demonstrates that stenting the LCx ostium should be considered after covered stent implantation from LM to LAD, because balloon angioplasty of the LCx ostium may not provide a durable result in this scenario.