LM Bifurcation Stenting with Crush Technique

- Operator : Seung-Jung Park

LM Bifurcation Stenting with Crush Technique
- Operator: Seung-Jung Park, MD
Case Presentation
A 85 year-old male patient was admitted for effort chest pain aggravated from 2 weeks ago. He had a history of hypertension and diabetes mellitus. He underwent coronary angiography at other hospital 5 days ago. It revealed severe stenosis at LM bifurcation and triple vessel disease. The physical exam was normal. The ECG showed atrial fibrillation. Echocardiogram showed normal left ventricular systolic function without definite regional wall motion abnormality.
Baseline Coronary Angiogram & IVUS
  1. The Left coronary angiogram showed severe stenosis with heavy calcification at distal LM, proximal to mid LAD and proximal LCX, and moderate stenosis at distal LCX. ( Movie 1, Movie 2)
  2. The right coronary angiogram showed severe stenosis with heavy calcification at proximal to distal RCA. ( Movie 3)
Procedure
A 8 Fr sheath was inserted through right femoral artery and left coronary artery was engaged with a 8 Fr JL 4 guiding catheter. A 5 Fr sheath through left femoral artery and IABP was prepare for cardiogenic shock. 0.014-inch Sion 180 cm wire was inserted into LAD and 0.014-inch Sion 180 cm wire was inserted into LCX and OM. ( Movie 4) Pre-dilation was performed with a SAPPHIRE NC 2.5 x 18 mm balloon. And a Angiosculpt 3.0 x 15 mm balloon was used for heavily calcified lesions at LAD and LCX. Then, a SAPPHIRE NC 3.75 x 18 mm balloon was used for pre-dilation at LM to proximal LAD. A XIENCE Alpine 3.5 x 28 mm was successfully deployed at proximal LCX and XIENCE Alpine 3.0 x 28 mm and 3.5 x 38 mm were successfully deployed at LM to mid LAD by Crush technique. ( Movie 5, Movie 6). And additional NC ballooning was performed by using Raiden 3 3.0 x 20 mm at proximal to mid LAD and proximal LCX, SAPPHIRE NC 3.75 x 18 mm at proximal LAD and SAPPHIRE NC 4.0 X 15 mm at LM. Additional kissing ballooning was performed by using Raiden 3 3.0 X 20 mm at proximal LCX and SAPPHIRE NC 3.75 x 18 mm at LM to proximal LAD. ( Movie 7, Movie 8). Final angiogram ( Movie 9, Movie 10) and IVUS showed that the procedure was successful. And staged PCI for diffuse RCA lesion with heavy calcification was planned.

Appendix
IVUS image of post ballooning ( Movie 11), post stent implantation ( Movie 12) and final image ( Movie 13) of LAD.
IVUS image of post ballooning ( Movie 14) and final image ( Movie 15) of LCX.

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