IVUS Guided Double Kissing Crush Stenting for Bifurcation Lesion

- Operator :

IVUS Guided Double Kissing Crush Stenting for Bifurcation Lesion
- Operator: Mokoto Sato, MD
Clinical Characteristics
A 54-year old man was admitted with resting chest pain for several months. Her coronary risk factor was hypertension and hyperlipidemia. His baseline ECG showed Q waves at anterior precordial leads. He had prior history of acute myocardial infarction, which was treated with bare-metal stent implantation at proximal LAD about 17 months ago.
Baseline Coronary Angiography

1. Left coronary angiogram showed mild stenosis at proximal LAD BMS site and moderate stenosis at mid LAD with severe stenosis of proximal-mid LCX and moderate stenosis at large 14PL branch (Figure 1, Figure 2, Figure 3).
2. Right coronary angiogram showed diminutive RCA (Figure 4).

Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8F XB catheter with 3.5 cm curve. Two 0.014 inch Rinato and Runthrough guidewire were inserted into the LAD and LCX respectively with Progreat microcatheter (Figure 5, Figure 6).
After balloon dilation (2.75 mm) (Figure 7, Figure 8), first 2.5 X 28 mm Cypher stent was implanted in LCX-14PL and crushed by main branch balloon with 2.75 mm, sequentially (like balloon Crush technique) (Figure 9, Figure 10, Figure 11, Figure 12). Then guidewire was recrossed to side branch. To get optimal opening and coverage of side branch ostium, recross-guidewire has to be crossed center of side branch ostium. In the case, we checked recross-guidewire position by IVUS, and in the 3rd try recross-wire successfully crossed into the center of 14PL ostium (Figure 13, Figure 14). After successful proper guidewire recrossing, we performed 1st KBT before main branch stenting (2.75 X 2.5 mm) (Figure 15), then main branch stenting with two 3.0 X 33 mm Cypher (Figure 16, Figure 17), finally 2nd (final) KBT (2.75 X 2.5 mm) (Figure 18). The final result was optimal in both angiogram and IVUS which might promise better subacute and late result (Figure 19, Figure 20).
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Comments

  • Marcelo Ribeiro 2007-04-27 You know, I am one of those guys who completely hate the crush technique. I congratulate you to try put an extra-dose of credibility to the crushing , limitating at maximum the crushed segment, doing two Kissing balloon inflations, certifying yourself of the true position of the guidewire by IVUS.But, this was at the proximal lesion a IVb lesion( Lefevre classification), I am pretty sure it could have been done by provisional or T stenting .Anyway, it is a nice demonstration.Thank you

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