Coronary angiogram showed
a critical stenosis in proximal LAD, at the bifurcation
to D1 (Figure
1). A large cholesterol plaque
overhung & prolapsed into the ostial D1.
Diffused stenosis of about 50% was noted in the
proximal to mid RCA (Figure
2). The LCX was small
and subtotally occluded. The critical bifurcated
lesion was first tackled and several strategies
were to be considered:
1. Debulking with Flexicut
and then stent the bifurcated lesion,
2. Provisional
T stenting with DES
3. Traditional
crush stent technique with DES and finish with
final kissing.
Since
the D1 was relatively large and the angle between
the main branch (LAD) and the side branch (D1)
was less than 70 degrees (Figure
3), strategy
3 was adopted. I hope that restenosis rate
of both vessels can be kept close to a single
digit figure.
A 7F EBU3.5 guiding was used for a better
backup support. The LAD was wired easily with
a polymer hydrophilic coated Pilot 50 guidewire
(Figure
4). However, the D1 was so
difficult to be wired due to the overhanging
plaque. The pLAD was first dilated with a cutting
balloon 2.5 X 6 mm so as to change the geometry
of the plaque at the bifurcation. Besides, the
tip of another Pilot 50 GW was shaped like an
"S" and then rotated into the D1 (Figure
5). Both the
main branch and the side branch were adequately
dilated with the cutting balloon. A Taxus 2.5
X 24 mm was placed from the LAD to the D1 and
another Taxus 3.0 X 28 mm was placed from the
proximal LAD to mid LAD (Figure
6). The D1 stent
was deployed first and inflated up to 14 ATM
and then the balloon and wire was withdrawn.
The LAD stent was deployed with inflation pressure
up to 12 ATM, crushing the D1 stent (Figure
7)
against the wall of the main branch just proximal
to the D1 ostium.
In order to achieve a lower restenosis
rate at the side branch (35% to 12.5%, according
to Colombo 's series), final kissing has to
be done. So, the D1 was rewired easily with the
Pilot 50 in the LAD and the LAD was wired again
with the previously withdrawn guidewire. A
Voyager 2.0 X 8 mm crossed the stent struts into
the D1 without any difficulty (Figure
8). The
cell was enlarged gradually. A second Voyager
2.5 X 15 mm was subsequently placed in the D1.
Final kissing was completed by simultaneous inflation
of another Voyager 3.0 X 20 mm in the LAD,
both up to 14 ATM (Figure
9).
Final angiogram showed
a very successful result without residual stenosis
(Figure
10).
The most
challenging part of the Crush technique is
the rewiring and getting the balloon through
the 2 layers of stent mesh at the bifurcation.
Pilot 50 and the Voyager balloon have demonstrated
their crossability in this difficult situation. |
