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Crushing Technique with Two Cyphers and Kissing Balloon Dilatation for Left Anterior Descending Artery Bifurcation Stenosis

- Operator: Myeong-Ki Hong, MD, PhD, Bong-Ki Lee, MD
Case presentation
The patient was a 58 year-old male. He presented with effort chest pain for 3 months. His coronary risk factor was smoking. His baseline ECG and echocardiography showed normal findings.
Baseline coronary angiography
Left coronary angiogram showed significant stenosis at the left anterior descending artery (LAD) bifurcation (Figure 1). Right coronary angiogram was normal.
Procedures
An 8F EBU 3.5 guiding catheter was engaged into the left main ostium. A 0.014 inch Floppy wire was introduced into the LAD and another guide wire (0.014 inch Choice PT) was introduced into the first diagonal branch (D1) (Figure 2). Using a Maverick balloon (2.5 X 20 mm, Boston Scientific), LAD and D1 branch lesions were alternatively dilated (Figure 3, Figure 4). Two Cypher stents (3.5 X 23 mm in LAD and 2.5 X 23 mm in D1) were positioned for Crushing technique (Figure 5). The side-branch stent is deployed first and the guide wire was removed. Then, the stent in the main branch was expanded and the protruding strut of the side branch stent were crushed against the main vessel wall (Figure 6, Figure 7, Figure 8). For final kissing balloon dilatation, the side branch was rewired using a Choice PT wire (Scimed) and balloon dilatation was performed with a Hayate balloon (1.5 X 20 mm, Terumo) for reopening of the side branch (Figure 9). Then, final kissing balloon dilatation was performed with a Maestro balloon (3.0 X 20 mm, Jomed) in LAD and a Stormer balloon (2.5 X 15 mm, Medtronic) in D1 (Figure 10). Additional ballooning was done at proximal in-stent segment of main branch (Figure 11). Final left coronary angiogram showed no residual in-stent narrowing in both branches (Figure 12, Figure 13).
Follow up angiography
At 6 months after the procedure, the follow up coronary angiography was performed with a 5F Judkins catheter through the radial approach. The left coronary angiogram showed patent stented segments (Figure 14).
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