Two Bifurcation PCI with the Crush Technique

- Operator : Seung-Jung Park

Two Bifurcation PCI with the Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 51 year-old male visited hospital for effort chest pain since 6 months. He had hypertension. Physical examination, simple chest radiograph, and 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 diffuse severe stenosis from distal LM to proximal LAD, tubular lesion at proximal LCX ( Movie 1, Movie 2, Movie 3).
  2. The right coronary angiogram showed diffuse moderate stenosis at mid to proximal RCA with negative FFR (0.88) ( 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. Three 0.014-inch BMW 190 cm wires were inserted into LAD, diagonal branch and LCX. After pre-ballooning with Emerge NC 2.5 x 20 mm up to 20 atm (2.61) and up to 6 atm (2.34) for the LM to proximal LAD and diagonal ostium respectively, IVUS imaging revealed diffuse large plaques from mid LAD to LM ( Movie 5) and eccentric plaque at diagonal branch ( Movie 6), large plaque at proximal LCX ( Movie 7). Xience Sierra stent sized 3.5 x 18 mm was deployed at the pLCX ( Movie 8) and post-ballooning with Neon NC 3.5 x 20 mm up to 20 atm (3.68), balloon crushing with NC TREK 4.0 x 20 mm up to 24 atm (4.3) were carried out. Xience Sierra 2.5 x 23 mm was inserted at diagonal lesion and post-ballooning with Emerge NC 2.5 x 20 mm up to 28 atm (2.7) and Emerge NC 1.5 x 15 mm up to 18 atm (1.7), and then balloon crush with Neon NC 4.0 x 20 mm up to 20 atm (4.19) were performed. LM to proximal LAD lesion was pre-dilated with Neon NC 3.5 x 20 mm up to 20 atm (3.68) and Xience Sierra 3.5 x 38 mm was inserted ( Movie 9). Subsequently, post-ballooning was performed with NC ROVL 4.0 x 20 mm up to 28 atm (4.3). Kissing ballooning for LM to proximal LAD and diagonal branch was done with Neon NC 3.5 x 20 mm up to 10 atm (3.44) and Emerge NC 2.5 x 20 mm up to 10 atm (2.47) respectively ( Movie 10). Another kissing balloon was performed at LM to proximal LAD and proximal LCX with NC ROVL 4.0 x 20 mm up to 13 atm (3.97) and Neon NC 3.5 x 20 mm up to 13 atm (3.53) respectively ( Movie 11). Final angiogram showed successful results ( Movie 12, Movie 13).

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