Slides

Provisional T Stenting for Jailed and Dissected Diagonal Branch

- Operator : Seung-Jung Park

Provisional T Stenting for Jailed and Dissected Diagonal Branch
- Operator: Seung-Jung Park, MD
Case Presentation
A 54 years-old man visited our hospital presenting effort-related chest pain that was aggravated by cold exposure, since about 1 year ago. His coronary risk factors were hypertension and smoking. He had smoking history of 30 pack-years. The electrocardiogram presented no significant ischemic change except Q wave in lead III. The echocardiography showed normal left ventricular function (EF=57%) without regional wall motion abnormality.
Baseline coronary angiography
1. The right coronary angiogram showed tubular 80% stenosis of posterior lateral branch. ( Movie 1)
2. The left coronary angiogram showed diffuse 70~80% stenosis of proximal to mid LAD which presented reduction of FFR from 0.89 to 0.62 after induced maximal hyperemia.( Movie 2)
Procedure
We planned to perform PCI for proximal to mid LAD lesion. An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with a 8Fr XB 3.5 catheter with side hole. A 0.014 inch BMW wire was inserted into the LAD. We pre-dilated proximal to mid LAD using a Maverick 2.0 x 20 mm balloon. Thereafter, we deployed a Resolute integrity 3.5 x 12 mm stent and a Resolute integrity 3.0 X 38 mm stent at proximal to mid LAD, sequentially ( Movie 3). After successful deployment of the stents, we performed adjunctive post-stenting balloon dilatation with Ikazuchi 2.5 X 15 mm balloon and Dura star 2.75 X 15 mm balloon in sequence. However, unfortunately the patient presented sudden chest pain and angiogram revealed that the diagonal ostium was significantly jailed ( Movie 4). We immediately performed balloon dilatation with Maverick 1.5 X 15 mm balloon and Maverick 2.0 X 20 mm balloon, but then angiogram showed severe dissection in diagonal branch ( Movie 5). We tried to identify the characteristics of the lesion by IVUS, but IVUS catheter could not pass through the diagonal lesion. After several times of balloon dilatation, we could introduce the IVUS catheter and identify a tiny hematoma. We performed bail-out stenting for the diagonal os lesion. We deployed Resolute integrity 2.5 X 30 mm stent, successfully ( Movie 6). And then we performed kissing balloon angioplasty with a Maverick 2.0 X 20 mm at diagonal instent and a Dura star 2.75 x 15 mm at mid LAD ( Movie 7). After kissing balloon angioplasty, final left angiogram and IVUS showed that the procedure was successful ( Movie 8).

Comments

  • Ajay Gandhi 2012-04-21 Good case, but I think he would have lost his angina if the Pl RCA was adressed
  • Stanley 2012-04-30 Thanks for sharing cases with us. Is the side branch stenting so-called " TAP" technique?
  • lxiaokun 2012-04-30 RCA stenosis is culprit lesion,why not treat it first?
  • Bing Liu 2012-05-01 It was not a acute or emergency case, so if FFR was in RCA, it would be significant also.But as we can see it was just a small RPL, and FFR in LAD was 0.62. I would treat LAD also firstly. This strategy was reasonable! But what was your final type of the bifurcation,reverse crush or modify-T stent?
  • Won-Jang Kim 2012-05-02 Thank for valuable comments, collegues. For the LAD bifurcation, we did a provisional stenting conceptually and finally did a reverse 'TAP' technique for coverage of ostium part of diagonal branch. After LAD stenting, we also fixed the PL branch with POBA.
  • Long Bui 2014-08-01 Thanks for sharing your case. Some questions for you: Why did dissection occure in side branch? Why did you use a smaller balloon for post-dilatation? 1 or 2 step kissing balloon did you apply?

Leave a comment

Sign in to leave a comment.