Slides Coronary

LAD Bifurcation Treated by Balloon Crush Technique

- Operator : Duk-Woo Park

LAD Bifurcation Treated by Balloon Crush Technique
- Operator: Duk-Woo Park, MD
Case Presentation
A 58 year-old female was admitted with effort chest pain for a year. Her coronary risk factors were hyperlipidemia and diabetes mellitus. The physical examination was normal. Her baseline ECG and cardiac markers were unremarkable. She received drug-eluting stent (Promus 3.5 x 28 mm) implantation at proximal to mid RCA about 1 year ago due to acute myocardial infarction. Echocardiography showed a normal left ventricular ejection fraction of 55% with regional wall motion abnormality of the RCA territory.
Baseline Coronary Angiography
  1. The left coronary angiography showed diffuse subtotal occlusion of proximal LAD, severe stenosis of 1st diagonal branch, and diffuse moderate stenosis of distal LCX ( Movie 1, Movie 2).
  2. The right coronary angiogram showed proximal to mid RCA stent was patent ( Movie 3).
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8F JL 4.0 catheter. 0.014-inch 190cm BMW wire was inserted into the LAD. Considering tight bifurcation lesion of LAD, we planned PCI with 2 stents by crush technique. First, we pre-dilated proximal to mid LAD using 2.5 x 20 mm Lacrosse balloon and then, 0.014-inch 180cm Runthrough NS wire was inserted into the 1st diagonal branch. We dilated proximal to mid LAD using 2.75 x 20mm Quantum balloon (Figure 1) and 1st diagonal branch using Lacrosse 2.5 x 20 mm (Figure 2). Thereafter a Resolute Onyx 2.5 x 26 mm stent was successfully deployed at 1st diagonal branch (Figure 3). And then we did balloon crush with 2.75 x 20 mm Quantum balloon (Figure 4). Because of heavy calcification of proximal to mid LAD, there was difficulty in stent delivery even after dilatation with 3.5 x 10 mm Flextome cutting balloon (Figure 5). So 5F heart rail was used to implant Resolute Onyx 3.5 x 22 mm and 4.0 x 22 mm stents at proximal to mid LAD (Figure 6, Figure 7). And 1st diagonal branch rewired with 0.014-inch 180cm Choice PT. Final kissing ballooning was performed by using an Empira NC 3.5 x 20 mm at proximal to mid LAD and a Lacrosse 2.5 x 20 mm at the 1st diagonal branch (Figure 8). Final left angiogram showed that the procedure was successful ( Movie 4, Movie 5).

Comments

  • Kunal Bikram Shaha 2016-10-14 well attemped sir,what are your comments regarding unerexpansion because of the calcium in mid lad stent--Do you think rotablation was required or flexome induced cut in different directionwas required to be proof read by IVUS,what do you think is better a snugging i.e mini kissing or conventional kissing ....was there use of IVUS in this case.....
  • Se Hun Kang 2016-10-14 Thank you for your comment. As you mentioned, rotablation and cutting balloon could be a good modality in case of heavy calcification. After discussion, we concluded that rotablation would not be a good choice, because of minimal lumen area lesion was not so small. Rotablation burr would not be fit for this lesion. Regarding cutting balloon, we did cutting balloon dilatation in different direction about three times. But after mutiple dilatation with cutting balloon, the lesion was not fully expanded in this case.

Leave a comment

Sign in to leave a comment.