Left Main Bifurcation Lesion Including Dissection Flap Treated with Mini-Crush Technique and High-Pressure Kissing Balloon
- Operator: Antonio Colombo, MD
Clinical presentation
A 64-year old man was admitted with chest pain for 3 months. Three months ago, intervention was done at other hospital, but failed. His risk factors were hypertension and smoking. Baseline ECG showed nonspecific ST-T changes. Echocardiography showed normal LV systolic function without regional wall motion abnormality.
Baseline coronary angiogram
1. Left coronary angiogram showed LM bifurcation stenosis with proximal LAD and proximal LCX stenosis. Dissecting flap was observed at LM shaft, which might be due to previous guiding catheter-induced injury (Figure
1, Figure 2 and Figure 3).
2. Right coronary angiogram was diffuse 30-40% narrowing (Figure 4).
Procedure
An 8F sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8F JL catheter with 3.5cm curve. Three 0.014 inch BMW wires were inserted into the LAD, RI and LCX, respectively (Figure 5 and Figure 6). LM reference diameter based on IVUS was about 7 mm. A 3.5 X 16 mm Taxus stent was positioned at the distal LM to proximal LCX, and a 4.0 X 24 mm Taxus stent was positioned at the LM os to proximal LAD (mini-crushing technique). Then, a Taxus stent of LCX was dilated at 18 atm (3.92 mm) (Figure 7), followed by a Taxus stent of LM to LAD was dilated at 16 atm (4.42 mm). After re-wiring into LCX using 0.014 inch Rinato wire, additional balloon dilatation at LCX os was done with Quantum balloon 3.5 X 12 mm upto 26 atm (3.82 mm) (Figure 8). And then, additional balloon dilatation at LM was done with Quantum balloon 4.0 X 12 mm upto 26 atm (4.35 mm). Kissing balloon was performed with Quantum balloon 4.0 X 12 mm upto 24 atm (4.3 mm) at LM to LAD and Quantum balloon 3.5 X 12 mm upto 24 atm (3.77 mm) at LCX (Figure 9). Final angiogram showed a well-expanded stents without residual narrowing (Figure 10 and Figure 11).
