LM Bifurcation Stenting with the Crush Technique

- Operator : Seung-Jung Park

LM Bifurcation Stenting with the Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 48 year-old male was admitted for dyspnea on exertion started from 2 months ago. His medical history was unremarkable. Physical examination, simple chest radiograph, electrocardiography were unremarkable. Echocardiogram showed normal left ventricular systolic function without regional wall motion abnormality.
Baseline Coronary Angiogram & IVUS
  1. The left coronary angiogram showed tubular lesion at LM, diffuse stenosis at proximal to mid LAD, diffuse severe stenosis at pLCX and OM2 ( Movie 1, Movie 2, Movie 3).
  2. The right coronary angiogram showed tubular moderate stenosis at mid RCA and diffuse moderate stenosis at distal RCA to PDA with negative FFR (0.81) ( Movie 4).
Procedure
An 8 Fr long sheath was inserted through the right femoral artery and left coronary artery was engaged with an 8 Fr JL 4.0 guiding catheter. Two 0.014-inch BMW 190 cm wires were inserted into LAD and diagonal branch. 0.014-inch Sion 180 wire was inserted into LCX to OM. Xience Sierra sized 2.75 x 38 mm was deployed at proximal to mid LAD ( Movie 5) and two Xience Sierra stent sized 2.75 x 28 mm and 2.75 x 15 mm were deployed at proximal LCX to OM and proximal LCX respectively ( Movie 6, Movie 7). After IVUS evaluation for stent optimization, mini-crush ballooning using Sapphire NC 3.5 x 18 mm up to 14 atm (3.56) was performed ( Movie 8). Another Xience Sierra sized 3.5 x 28 mm was inserted into LM to proximal LAD. Post-ballooning with Emerge NC 3.0 x 20 mm up to 18 atm (3.1) and Euphora 2.0 x 12 mm up to 18 atm (2.35) at mid to proximal LAD stent and Sapphire NC 3.5 x 18 mm up to 28 atm (3.9) at LM to proximal LAD stent were performed. Subsequent post-ballooning procedures at proximal LCX to OM stent using Emerge NC 3.0 x 20 mm up to 28 atm (3.3) and at proximal LCX stent using Lacrosse 1.3 x 10 mm up to 18 atm (1.74) were performed. Kissing balloon procedure was performed at LM to proximal LAD and proximal LCX using Sapphire NC 3.5 x 18 mm up to 10 atm (3.44) and Emerge NC 3.0 x 20 mm up to 10 atm (2.96) respectively ( Movie 9). Another kissing ballooning was performed at same site using stent balloon 3.5 x 28 mm up to 10 atm (3.47) at LM to proximal LAD and Emerge NC 3.0 x 20 mm up to 10 atm (2.96) ( Movie 10). Final angiogram showed successful results ( Movie 11, Movie 12).

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