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Treatment The procedure was carried out on an Artis zee floor-mounted angiography system. The therapeutic strategy for this patient mainly depended on good knowledge of the positions of the stents that were implanted around ten years prior. Given that traditional angiographic images make it difficult to accurately view the edges of the implanted stents, it was decided to use the CLEARstent software in order to precisely assess the positions of the old stents in relation to the left main artery. CLEARstent requires balloon or similar markers to align the individual images of a coronary angiogram for enhancement. As the coronary flow could be compromised by a thick balloon crossing the stenosis, we decided to use a special, thinner ATW guide wire featuring CLEARstent detectable markers at 10 mm intervals and with a diameter of 0.0076 inch. In addition, the wire would also enable a conventional angioplasty to be carried out (Fig. 2). With the guide wire placed in the anterior interventricular artery (Fig. 3), the CLEARstent images with and without contrast injections first confirm the positioning of the old Cypher stent in the proximal part of the LAD. It protruded about 1 millimeter into the left main artery covering the ostium of the Multilink stent, which was positioned in the circumflex artery. The contrast injection made it possible to assess the extent of calcification which obscured the previously implanted stent in the angiography images (Fig. 3). We then positioned the ATW guide within the LCX so we could see more CLEARstent Cardiology accurately the Multilink stent and confirm that it was indeed aligned with the ostium of the circumflex artery and not protruding into the left main artery (Fig. 4). Guided by this information, we predilated the anterior interventricular artery ostium with a high-pressure 3 mm balloon and also predilated the circumflex artery ostium with a very high-pressure balloon (Fig. 5). A 16x3.5 mm Boston Scientific Taxus Element stent was placed in a crossover position starting in the left main artery and towards the LAD, with a 3 to 4 mm overlap with the old Cypher stent. Positioning was reconfirmed using CLEARstent without contrast injection (Fig. 6). Then the Taxus stent was implanted at 16 atmospheres. 3B CLEARstent Dynamic (A) and CLEARstent (B) enhanced images used for diagnostic overwiev showing the Cordis ATW marker wire and previously implanted stents in LAD and LCX. 2 3A 2 ATW Marker Wire. 3 4 5A Second CLEARstent image shows exact alignment of implanted stent with ostium of circumflex branch. 4 3 cm radiopaque tip Markers Cypher Stent LAD Cypher Stent LAD Multilink Stent CX ATW marker wire Cordis LAD calcification LAD calcification Guide ATW 5B Multilink Stent CX 5 Pre-dilatation of LAD (A) and LCX (B). AXIOM Innovations | December 2013 | www.siemens.com/angiography  37


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