Case Title

An Approach to Bifurcation Lesion

Case History

A 48 year old hypertensive gentleman with a strongly positive stress test, a low work load with a high calcium score on CT Angiography and a normal LV function on 2D Echo and with a strong family history of IHD.

Investigation Reports

Click on the thumbnail images to see the videos

RAO 30 and caudal 20. Note: Proximal and critical stenosis of LAD, CIRC shows truly bifurcation lesion at the site of large OM branch The bifurcation lesion in the CIRC clearly shows an osteal lesion in the large OM branch, critical lesion in the parent stem and osteal lesion in distal vessel. RCA shows tight osteal lesion in one of the side branches arising from the posterolateral division of the RCA.

After addressing and stenting LAD lesion using a 3x16 taxus stent bifurcation stenosis was addressed and the following points were observed:

1. Whilst addressing the bifurcation lesion it is advisable to use 7 f guide catheter.
2. Currently available 6 f guide catheters may accommodate 2 kissing stents but 7f is better for good guide injections along with 2 stents.
3. OM branch was wired with BMW wire first and the idea is one should always wire a difficult branch first.

Subsequently another BMW was advanced into parent LCX and parked distally. A 2.5 mm maverick balloon was positioned and inflated. Note the waist in the OM branch. Subsequently the parent LCX lesion was dilated with 3 mm maverick balloon. Unfortunately there was elastic recoil in the OM osteal lesion and an ugly dissection in the LCX artery extending proximally for about 10 mm. Although LCX artery did not give any important branch but patient was developing extreme bradycardia while dilating the LCX artery, probably, due to sinus node ischemia, since sinus node is supplied by LCX through large recurrent arterial branch. The best and easiest approach is to do a bifurcation stenting using crush technique. A 2.5x16 mm taxus stent was positioned across the lesion in the OM branch. Simultaneously 2.5x12 mm taxus stent was placed across the LCX branch. In crush technique, the principle stent should extend atleast 3 mm beyond the proximal point of a stent placed in the less important branch. Notice here that the OM branch stent is extending 3 mm proximal to the LCX stent. Angiographic verification of a proper placement of 2 stents. One must deploy now the side branch stent fully . At this stage make sure that the 2nd stent placed in the OM branch should not move. After fully deploying the LCX stent, its balloon and its wire were removed, and check shoot was done as is seen in cine 28. Now the OM branch stent was fully deployed. Note excellent results of the bifurcation lesion

Advantages of crush technique:

1. It is user friendly.
2. Produces excellent angiographic results.

Disadvantages of crush technique:

1. There would be 3 layers of drug coated stent material on the wall adjacent to the crushed area. Long term results not known.
2. Re-entering the side branch may have to cross three layers of stent and this may be technically very difficult.

Courtesy

Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.

Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com