Double Bifurcations Treated by Crush and Crush

- Operator : Seung-Jung Park

Double Bifurcations Treated by Crush and Crush
- Operator: Seung-Jung Park, MD
Case Presentation
A 64 year-old male was admitted with effort chest pain for 2 weeks. His coronary risk factors were hypertension and dyslipidemia. The baseline ECG, echocardiography and cardiac markers were not remarkable. But on thallium SPECT, both LAD and LCx territories showed reversible large sized perfusion defects and preserved LV function.
Baseline Coronary Angiography
  1. The left coronary angiography showed diffuse 60% stenosis of p-mLAD, diffuse 90% stenosis of big D1. Proximal LCx showed tubular 80% of stenosis with high take off of big OM1. ( Movie 1, Movie 2) The p-mLAD FFR measured 0.86 to 0.74 while administrating 140mcg/kg/min of IV adenosine.
  2. The right coronary angiogram was normal. (Figure 1)
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. Two 0.014-inch Sion wires were inserted into the LAD and D1, respectively. D1 was pre-dilated with 2.0 x 20 mm Maverick balloon and a Resolute Integrity stent 2.75 x 15 mm was deployed at D1. (Figure 2) Then we performed crushing with Quantum balloon 3.0 x 20 mm at mLAD. (Figure 3) The D1 wire was removed and repositioned into the LCx proper. ( Movie 3) pLCx was pre-dilated with 2.0 x 20 mm Maverick balloon and a Resolute Integrity stent 3.0 x 26 mm was deployed at pLCx. (Figure 4) Then, we did crushing with a Resolute Integrity stent 3.5 x 38 mm at p-mLAD to LM shaft. (Figure 5) The LCx wire was removed and repositioned into the D1 and Ikazuchi balloon 1.2 x 6 mm, Maverick balloon 2.0 x 20 mm were sequentially used to open the D1 ostium. Using Empira NC balloon 2.75 x 15 mm and Quantum balloon 3.0 x 20 mm, we did final kissing for mLAD bifurcation site. (Figure 6) The D1 wire was removed and repositioned again into the LCx and we did final kissing for proximal LAD and proximal LCx using Quantum balloon 3.5 x 20 mm and Quantum balloon 3.0 x 20 mm, respectively. (Figure 7) Final left angiogram and IVUS showed that the procedure was successful ( Movie 4, Movie 5).

Comments

  • Kunal Bikram Shaha 2016-07-29 sir what is your opinion on residual disease left uncovered in diagonal just distal to stent .Could it be prevented if we could have taken a bit longer stent with 2.25 size....
  • Se Hun Kang 2016-07-29 Thank you for your comment. As you mentioned, there was residual stenosis in diagonal branch At first, diagonal branch was dilated with 2.0 x 20 mm balloon and 2.75 x 15 mm stent was implanted. Even we selected 2.25 balloon there could be some residual stenosis on diagonal branch and in this case mild residual stenosis on diagonal branch would have little impact on clinical outcome.

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