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Stent-Crush for a Left Main Trifurcation Lesion with Sirolimus-Eluting Stents

- Operator: Myeong-Ki Hong, MD

A 62 year old man was admitted with effort angina for 6 months. His risk factors were hypertension and diabetes mellitus. His baseline ECG and echocardiogram was normal. Baseline coronary angiogram showed significant stenosis at left main (LM) trifurcation site involving ostial left anterior descending artery (LAD), ostial ramus intermedius (RI) (Image 1, Image 2, Image 3).

Procedure

We planned to insert Cypher stents in all three branches by duplicated stent crushing technique. A 9F EBU 3.5 guiding catheter was engaged at the left coronary. Three 0.014 inch guide wires were inserted into the LAD, RI and LCX (Image 4). A 3.0 x 33mm Cypher stent was deployed at the middle LAD to 16atm (3.21mm) (Image 5, Image 6). LAD ostium, RI ostium and LCX ostium were sequentially dilated with a 3.0 x 10mm Cutting balloon at 12 atm (3.09mm), 6atm (2.96 mm), and 12atm (3.09 mm), respectively (Image 7, Image 8, Image 9). Then, a 2.75 x 28 mm Cypher stent was placed at RI and a 3.5 x 33 mm Cypher stent was placed at LCX (Image 10). The two stents were minimally protruded to the LM bifurcation for preparing stent-Crush. RI stent was deployed first at 14 atm (2.91mm) and LCX stent was deployed at 12 atm (3.6mm) (Image 11, Image 12, Image 13). Then, proximal LAD to LM was dilated with a Maverick balloon (3.0 x 20mm) at 16atm (3.46mm) with crushing the protruded portion of RI and LCX stents (Image 14). Then, a 3.5 x 33mm Cypher stent was placed at the proximal LAD to LM with overlapping and deployed at 12 atm (3.6mm) (Image 15, Image 16). A high pressure post-dilatation was performed with a 4.0 x 12 mm Sprinter balloon at 14 atm (4.36mm) (Image 17). Additional post-dilation was also performed sequentially at RI (Maverick 2.5 x 20mm at 14 atm [2.83mm]), LCX (Maverick 3.0 x 20mm at 6 atm [3.0mm]) and LM to LAD (Sprinter 4.0 x 12 mm at 14 atm [3.67mm]) (Image 18, Image 19, Image 20). Finally, a simultaneous triple kissing balloon dilatation was performed in LM to LAD, RI and LCX at 12 atm (3.5mm), 6 atm (2.5mm) and 6 atm (3.0mm), respectively (Image 21). The final angiogram showed successful result (Image 22, Image 23, Image 24).

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