Two Bifurcations PCI

- Operator : Seung-Jung Park

Two Bifurcations PCI
- Operator: Seung-Jung Park, MD
Case Presentation
A 72-year-old male patient was admitted for PCI at the left main, LAD, and LCX.
She has complained recently aggravating effort chest pain since a few months ago. She visited the cardiology clinic and hospitalized for further assessment. Echo showed normal LV function, but coronary angiogram showed left main disease, diffuse LAD disease and LCX ostium stenosis. The RCA showed intermediate lesion with negative FFR. The staged PCI was scheduled.
Her only coronary arterial risk factors were hypertension. Her electrocardiogram showed normal sinus rhythm. Echocardiography revealed normal LV EF without regional wall motion abnormality.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed intermediate lesion at mid to distal RCA with negative FFR (0.87) ( Movie 1).
  2. The left coronary angiogram showed significant left main disease, diffuse LAD disease with diagonal stenosis, and LCX os stenosis ( Movie 2, Movie 3).
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 guiding catheter. We planned bifurcation strategy (crush) for LM bifurcation and simple crossover strategy for LAD and diagonal bifurcation. Two BMW wires were inserted into the LAD and LCX for protection. After pre-ballooning for the LCX with Tazuna 2.5 (15) upto 14 atm (2.73), Xience Sierra 2.75 (15) stent was deployed at LCX ositum and crushed by Sapphire NC 3.5 (18) balloon from LAD side (Figure 1, Figure 2). We inserted Xience Sierra 3.5(23) at mid LAD and it crossed over the diagonal branch and inserted Xience Sierra 4.0 (33) at LM to proximal LAD (Figure 3). Then, the patient complained chest pain and CAG showed compromised the diagonal branch without any flow ( Movie 4). We decided to open jailed the diagonal branch, but it was hard to find diagonal ostium ( Movie 5). Gaia 1st wire was used to open diagonal branch and IVUS showed about 10 mm subintimal passage of wire at the proximal diagonal branch and reentry to true lumen at the distal diagonal branch ( Movie 6). Therefore, we inserted Xience Sierra 2.5 (23) upto 18 atm (2.88) at the proximal diagonal branch (Figure 4). The Kissing balloon technique was used for bifurcation of the LAD and diagonal branch (Figure 5). The crushed LCX stent was rewired with the BMW wire and opened with IKAZUCHI 2.0 (15) (Figure 6). The Final step was kissing balloon technique for LM bifurcation (LAD : Sapphire NC 4.0 (15) upto 10 atm (3.93), LCX : Nimbus Salvo 3.0 (13)) (Figure 7). The final angiogram showed successful results ( Movie 7, Movie 8).

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