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Bifurcation Stenting with Crush Technique for In-Stent Restenosis at Left Anterior Descending Artery Bifurcation

- Operator: Myeong-Ki Hong, MD

Clinical Presentation

A 37-year old man presented with effort chest pain for 1 month. He received bare-metal stent (Driver 3.0 by 24 mm) for a significant stenosis at the middle left anterior descending artery (LAD) 7 months ago. Coronary risk factors were diabetes, hypertension and smoking. His baseline ECG and echocardiography showed normal findings.

1. Left coronary angiogram showed a critical in-stent restenosis (ISR) involving the middle LAD bifurcation
(Figure 1, Figure 2).
2. Right coronary angiography showed a normal finding.

Procedure

After engaging of an 8F XB 3.5 guiding catheter, a 0.014 inch Choice PT wires were introduced into the LAD and the first diagonal branch (D1) sequentially. Using a cutting balloon (3.25 mm x 10 mm up to 12 atm for LAD; 2.5 x 10 mm up to 12 atm for D1), LAD and D1 branch lesions were alternatively dilated. Coronary angiogram after pre-dilatation showed a serious dissection at D1 branch (Figure 3). Two Cypher stents (3.5 mm x 33 mm in LAD and 2.75 mm x 18 mm in D1) were positioned for Crushing technique. At first, the side-branch stent is deployed first and the guide wire was removed (Figure 4). Secondarily, the stent in the main branch was expanded to crush the protruding strut of the side branch stent against the main vessel wall (Figure 5). After then, additional high pressure ballooning at the LAD was performed (Figure 6). For final kissing balloon dilatation, the side branch was rewired using a Choice PT wire and balloon dilatation was performed with a Maverick balloon (1.5 mm x 20 mm up to 16 atm) for reopening of the side branch. Then, final kissing balloon dilatation was performed with a Sprinter balloon (3.0 mm x 15 mm up to 16 atm) in LAD and a Sprinter balloon (3.0 mm x 10 mm up to 16 atm) in D1 (Figure 7). Final left coronary angiogram showed no residual in-stent narrowing in both branches (Figure 8). Final intravascular ultrasound showed a widely opened ostium of D1 branch (Figure 9) and well-apposed multiple struts at the LAD.

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Joy M. Thomas2005-12-17
Superb result. Congratulations! I would like a follow-up angio after six months.
Yong He2005-12-18
Dr Hong,Perfect precedure and result! But I noticed that the previous stent is 3.0/24mm, why this time do you chose a 3.5/33mm stent for LAD? Is a 3.0mm stent more suitable in this situation? Yong, He
Young-Hak Kim2005-12-19
IVUS examination before procedure revealed that the plaque burden was extended to both edges and the stent was underexpanded as compared to the vessel diameter. Thus we put a long and large stent.
Marcelo Ribeiro2005-12-24
Congratulations for the perfect result!However, there is a trend now to abandon the crush technique as by ivus there is frequently underexpansion of the branch ostium , even after successful final kissing balloon.What was the final intrastent MLA at the diagonal ostium in this case?
Duk-Woo, Park2005-12-30
Thanks for your valuable comments. In this case, the final stent MLA at the diagonal ostium was a 5.5 mm2. Like this case, in our center experience, we think that crush technique with optimal final kissing balloon is good to ensure the ostium of side branch.
mardentebet2006-01-18
Why not SKS technique ?
mardentebet2006-01-18
Why not SKS technique ?
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