Left Main Bifurcation Coronary Intervention with Balloon Crush Technique

- Operator : Seung-Jung Park

Left Main Bifurcation Coronary Intervention with Balloon Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 72 year-old man was admitted with stable angina pectoris. His coronary risk factor was hypertension. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=60%) without regional wall motion abnormality.
Baseline Coronary Angiography
The left coronary angiogram showed a tubular 60% stenosis at left main shaft, significant diffuse narrowing from the proximal to middle left anterior descending artery (LAD) and diffuse 70~80% stenosis at proximal left circumflex artery (LCX) ( Movie 1, Movie 2, Movie 3).The FFR value using 140 mcg/kg/min intravenous adenosine infusion was 0.63 at mLAD portion.
Procedure
A 8Fr XB 3.5 SH guiding catheter was engaged in the left coronary artery through the right femoral artery. A 0.014-inch BMW wire was inserted into the LCX, another 0.014-inch BMW wire was inserted into the LAD. We predilated at LM to pLCX using Maverick 3.0 X 20mm balloon and Dura Star 3.0 X 15mm balloon (Figure 1, Figure 2) and deployed a PROMUS Element stent 3.0 X 28mm at dLM to pLCX, firstly. (Figure 3). And then, we performed balloon crushing with a Dura Star 3.0 X 15mm balloon at dLM to pLAD ( Movie 4). After predilatation with Dura Star 3.0 X 15mm balloon, PROMUS Element Stent 2.75 X 28mm and 3.5 X 38mm were implanted from mLAD to LM lesion, consecutively. (Figure 4, Figure 5). After IVUS examination, adjunctive post-stenting balloon dilatation using a Dura Star 3.0 X 15mm at proximal to mid LAD (Figure 6), another Voyager NC 4.0 X 15mm at LM to proximal LAD (Figure 7) and Sprinter legend 2.0 X 12mm at dLM to proximal LCX were performed. (Figure 8). Additional kissing ballooning was performed by using a Voyager NC 4.0 X 15mm at LM-pLAD and a Maverick 3.0 X 20mm at LM-pLCX ( Movie 5). Final left angiogram and IVUS showed that the procedure was successful ( Movie 6, Movie 7)

Comments

  • Vijay Shah 2011-09-06 Why call it Balloon crush technique....why not call it cullotte technique of treating bifurcation stenosis involving Lt main.?....dr v t shah ,mumbai,INDIA.
  • A.J.A 2011-09-10 What is the restenosis rate. Agha J.Ahmed, USA
  • Young-Hak Kim 2011-09-10 It is just a modification of class crush technique, which places the two stents simultaneously and crushes the side branch stent using the main branch stent. When the positioning of main stent is expected to be difficult after crush or the technique is done with small guiding cather, this is useful. Because the final stent configuration or geometry is same to classical one, the restenosis rate is anticipated to be same.
  • Po-Ming Ku 2011-09-11 Good job guided by FFR and IVUS. I consider DK-crush to be better. Po-Ming Ku. Taiwan.
  • Young-Hak Kim 2011-09-11 The DK crush is also a variant of Crush technique. It would also be fine.
  • curtis 2011-09-15 do u think the acute angle between lad and lcx is suitable for crush tech?
  • Tien-Yu Wu 2011-09-21 Congratulation! I also agree DK crush is good in this case! Tien Yu Wu Taiwan
  • Young-Hak Kim 2011-09-21 When the bifurcation angle is very steep, bifurcation stenting is not easy. The crush can be adopted but minimal protrusion of side branch stent is recommended to facilitate final kissing balloon inflation.
  • Marcelo Ribeiro 2011-09-30 I am a great fan of the provisional technique. In this case the lesion of left main was not critical, so i would use ivus first to confirm the absence of involvement of ostial LCX and then i would treat the LCX lesion and only do a simple crossover LM/Lad. I think the aspect of the result, geometrically speaking, is not natural... i wonder about the consequences of this in terms of flow distribution. But, anyway, a good overall result! I was expecting more branches to be missing at the end... i think this tells a lot about the improved stent design compared wit the taxus stent.
  • Young-Hak Kim 2011-09-30 I agree with the suggetions to point out the importance of IVUS guidance for left main stenting. Our decision is dependent on IVUS findings.
  • curtis 2012-10-28 I think the tech should be called modified T or mini-crush at most. The LCX stent protruded the MB very little (1mm according to the figure 3). Why do you not remove the LCX stent balloon while balloon crushing the SB stent? THANKS

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