Slides

LM Bifurcation Treated by Crush Technique

- Operator : Seung-Jung Park

LM Bifurcation Treated by Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 63 year-old female was admitted with an ongoing chest pain. His coronary risk factors were hypertension, diabetes and dyslipidemia. The physical examination was normal. The ECG showed pathologic Q-wave in anterior precordial lesion and CK-MB was slightly elevated as high as 16.0ng/mL. The echocardiography showed normal left ventricular function (EF=58%) with akinesia of LV apex.
Baseline Coronary Angiography
The left coronary angiography showed diffuse 50% stenosis of distal LM, subtotal occlusion of LAD ostium and diffuse 80% stenosis of proximal LCX. (Figure 1, Figure 2)
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8F JL catheter with 4.0 cm curve. A 9 Fr sheath was inserted at left femoral artery for the IABP implantation. 0.014-inch Soft wire was inserted into the LCX. By using the FINECROSS 0.014-inch 1.8Fr microcatheter, 0.014-inch Shinobi guidewire was inserted into LAD. After that, wire was exchanged by 0.014-inch 300cm BMW guidewire. Proximal LAD to LM was predilated with 2.75 x 20mm Maverick balloon. And then, we pre-dilated pLCX using 2.5 X 20mm Maverick balloon.(Figure 3) A PROMUS Element 3.0 X 16 mm Stent was successfully deployed at pLCX.( Movie 1) We performed crushing with a PROMUS 4.0 x 24 mm at dLM to pLAD.( Movie 2) Additional kissing ballooning was performed by using a Dura Star 4.0 X 15mm at LM-pLAD and a Dura Star 3.0 X 15mm at pLCX.(Figure 4) Final left angiogram and IVUS showed that the procedure was successful.(Figure 5)

Comments

  • Joao Alexandre Farjalla 2011-07-22 Great result!!!! Did you consider T stenting?
  • Won-Jang Kim 2011-07-23 Thanks for your kind comment. Yes, for the LM bifurcation lesion, there are few data on the optimal 2-stents techniques such as crush, T-, SKS, Y-, and so on. In this case, we knew the ostium of LCX had many plaques, based on the IVUS evaluation. We decided 2-stent techniques initially and chose the mini-crush technique in this patient.
  • Harris Ngow Ngow 2011-07-23 Thank you for this interesting case and good result indeed! Congrats! Do you have any criterion before embarking on which technique to choose since there are many 2 stents technique? Thank you...
  • cong hongliang 2011-07-23 Very good results,why did you consider mini T stenting? my idea is that Mini T stenting maybe better than Crush Technique. HONGLIANG Cong From tianjin Chest Hospital ,CHINA
  • Won-Jang Kim 2011-07-24 Many thanks for colleagues’ comments. Although we have limited data, classic T stenting showed high restenosis rate, caused by incomplete coverage of the ostial part of side branch (usually LCx) in distal LM stenting. This is reason why other techniques, such as the crush or kissing stenting, have been introduced. And we also did not want to overlap of multiple stent struts in distal LM. Modified T stenting, “T And small Protrusion(TAP)” was introduced by Colombo and colleagues. TAP techniques may be another options of 2-stent techniques in non-LM bifurcation lesions. Initially, we decided 2-stent techniques based on the IVUS information, and we wanted to cover the ostium of LCx, but escape from overlap of the multiple stent struts. And then we finally chose the mini-crush technique in this case.
  • Vijay Shah 2011-07-31 The Lcx was more at an angle of 90* and hence modified T technique appeared to be more reasonable so that minimal stent struts would be protuding ......drvtshah,mumbai,india.
  • Vijay Shah 2011-07-31 The Lcx was more at an angle of 90* and hence modified T technique appeared to be more reasonable so that minimal stent struts would be protuding ......drvtshah,mumbai,india.
  • Young-Hak Kim 2011-08-01 Modified T is also a reasonable approach. But the crush technique has an advantage to keep side branch open during the procedure. Because the LCX ostium was severely diseased, we adopted it.

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