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TCTAP C-066 Two-stage Triple Double-kissing Crush Technique in a Patient with Multiple Bifurcation Lesions
S156
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
We left the guidewire in LAD and tried to change a guiding catheter to extra backup support. We approached via left femoral artery using a 7Fr EBU 3.5 guiding catheter. After successful parallel wiring to LM to distal LAD with Sion black under EBU guiding catheter. We removed the previous Judkins guiding catheter. To enhance access to the lesion and provide additional backup support, we tried ‘child-in-mother’ technique using the Guidezilla guide extension catheter. After successful wiring with Grand slam to achieve maximal wire support, serial predilation was repeatedly done. Finally, we deployed the stent successfully.
Case Summary. Because the anatomy of the lesion was very tortuous and calcified, it was more difficult to do wiring and deliver the stent to the lesion. To tackle severely angulated lesion for safe wiring, we used Crusade microcatheter and “Reverse wire technique”. And, to enhance access to the lesion and provide maximal back-up support, we tried parallel wiring, anchor balloon technique and finally “child-in-mother technique”. Because a long stent might be impossible to pass the very tough lesion, we decided to deploy two short stents instead of deploying a long stent. TCTAP C-066 Two-stage Triple Double-kissing Crush Technique in a Patient with Multiple Bifurcation Lesions Shih-Hung Chan1 Section of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. Chen Relevant clinical history and physical exam. A 62 year-old male with hypertension and hyperlipidemia presented with crescendo angina pectoris. Treadmill exercise test revealed positive result for myocardial ischemia. Renal function and left ventricular systolic performance are normal. Physical examination did not reveal remarkable abnormal finding. Relevant test results prior to catheterization. Treadmill exercise test: positive for myocardial ischemia Echocardiography: Adequate LV systolic performance with LVEF 64% Multi-slice coronary CTA: 1. The calcium score is 89.0 2. LM-3VD showing multifocal plaques and stenosis with a) 50-69% stenosis at distal LM b) Near 90% stenosis at dLCX c) >70% stenosis at mRCA, dRCA, pLAD, D1 branch and pLCX d) 50-69% stenosis at pRCA, mLAD and OM branch
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Relevant catheterization findings. Coronary angiography: LM:70% stenosis at dLM LAD:70% stenosis at pLAD; 90% stenosis atD1 LCX:90% stenosis at LCX orifice, 99% stenosis at dLCX, 70% stenosis at OM1 RCA: Atherosclerosis
S157
Rewired the OM1. The balloon (1.25/10) was used to open OM1 stent KBT with a balloon (3.5/15) in LCX and a balloon (2.5/15) was done 3. A Resolute Integrity stent (3.5/38) deployed at LCX A balloon(3.5/15) was used to crush LM-LCX stent. Rewiredthe LCX A balloon(2.5/15) was used to open the LM-LCX stent A NC balloon(3.5/12)was used to dilate LM-LCX stent KBT with a NC balloon(3.5/12) in LM-LCX and a balloon(3.5/15)in LM-LAD was done 4. A Resolute Integrity stent(3.5/22) was deployed at LM-pLAD. A balloon (2.5/15) used to dilate D1 A Resolute Integrity stent(2.5/26) was deployed at D1 A balloon (3.0/20) used to crush LAD-D1 stent KBT with a balloon (3.0/20) in LAD and a NC balloon(2.5/10) in D1 was done. A Resolute Integrity stent (3.0/26) deployed at LAD. Rewired the D1 KBT with a NC balloon (3.25/15) in LAD and a NC balloon (2.5/10) in D1 was done A NC balloon (3.5/12) was used to dilate pLAD 5. Rewired the LCX. KBT with a NC balloon (3.5/10)in LM-LCX and a NC balloon (3.5/12) in LM-LAD was done. Rewired the OM1. KBTwith a NC balloon (3.5/10) in pLCX and a NC balloon (2.5/10) in OM1 was done A NCballoon(4.0/8) was used to dilate LM Case Summary. In order to completely, treat the bifurcation lesions in LM/LAD/LCX, LCX/OM1, LCX/OM2, and LAD/D1 bifurcation, we chose double kissing crush two-stent technique for LM/LAD/LCX, LCX/OM1, and LAD/D1 bifurcation. Unlike the standard procedure in traditional double kissing crush technique, we performed two-stage double kissing balloon angioplasty because of the complex triple bifurcation lesion in our patient. Using our modified methods, we can finish the complex lesions without difficulty. TCTAP C-067 Kissing Balloon Technique with Drug-coated Balloons Is Effective for Repeated In-stent Restenosis at the Bifurcation of Left Anterior Descending Artery and Left Circumflex Artery Mayumi Saso,1 Yuya Tanaka,1 Yoko Kurumatani,1 Kazuyoshi Ohata1 Kofu Kyoritsu Hospital, Japan
1
[CLINICAL INFORMATION] Patient initials or identifier number. T.N Relevant clinical history and physical exam. A 90’s year-old male admitted with chest pain. His coronary risk factors were hyperlipidemia, hypertension and diabetes mellitus. He is chronic kidney failure patient (BUN 15.6 mg/dl, SCR 1.10 mg/dl, eGFR 48.0 ml/min). ECG showed normal without ST changing. Echocardiography showed a normal left ventricular ejection fraction of 60%. This case is repeated in-stent restenosis of the bifurcation of a Left anterior descending artery (LAD) and left circumflex artery (LCX). Relevant test results prior to catheterization. He underwent stenting Cypher stent 3.0 28 mm (Cordis) at proximal LAD and stenting TAXUS stent 3.0 16 mm (Boston Scientific) at proximal left main trunk (LMT) to LAD with overlapping the stent nine years ago. Because of the progressing stenosis at LCX ostium he received stent LMT-LCX with mini crush (Cypher 3.0 18 mm). After that in-stent restenosis of LCX ostium occurred several times and done balloon angioplasty with kissing balloon technique each time. Relevant catheterization findings. However, re stenosis occurred at shorter interval times. Then he underwent Excimer laser Catheter ablation for LAD and LCX and was deployed Noobori stent 4.0 13 mm (Terumo) at middle LMT to LCX ostium lesion. After the eight months, Coronary angiogram showed 90% stenosis of the proximal LAD. [INTERVENTIONAL MANAGEMENT] Procedural step. 1. A 7Fr JL4 GC was used. The LAD, LCX,and OM2 were wired. KBT with a balloon(1.25/10) in OM2 and a balloon(3.5/15) indLCX was done. 2. Wired OM1. A balloon (2.5/15) was usedto dilate OM1 A Resolute Integrity stent (2.5/18) was deployed at OM1 A balloon(3.5/15) was used to crush the OM1 stent
[INTERVENTIONAL MANAGEMENT] Procedural step. We inserted an intra-aortic balloon pumping (IABP) into the left femoral artery for hemodynamic support during the intervention. A 7Fr EBU 3.5 catheter was engaged into the left coronary ostium.(Fig.1) The LAD was wired with a 0.014 inch Sion blue and LCX was wired with a 0.014-inch Run through Hypercoat. IVUS examination showed that there was concentric soft plaque in-stent at LMT distal to LAD ostium and LCX ostium. We dilated LAD using scoring balloon ( Lacross NSE 3.5 13 mm, Goodman) 14 atm. After
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
We left the guidewire in LAD and tried to change a guiding catheter to extra backup support. We approached via left femoral artery using a 7Fr EBU 3.5 guiding catheter. After successful parallel wiring to LM to distal LAD with Sion black under EBU guiding catheter. We removed the previous Judkins guiding catheter. To enhance access to the lesion and provide additional backup support, we tried ‘child-in-mother’ technique using the Guidezilla guide extension catheter. After successful wiring with Grand slam to achieve maximal wire support, serial predilation was repeatedly done. Finally, we deployed the stent successfully.
Case Summary. Because the anatomy of the lesion was very tortuous and calcified, it was more difficult to do wiring and deliver the stent to the lesion. To tackle severely angulated lesion for safe wiring, we used Crusade microcatheter and “Reverse wire technique”. And, to enhance access to the lesion and provide maximal back-up support, we tried parallel wiring, anchor balloon technique and finally “child-in-mother technique”. Because a long stent might be impossible to pass the very tough lesion, we decided to deploy two short stents instead of deploying a long stent. TCTAP C-066 Two-stage Triple Double-kissing Crush Technique in a Patient with Multiple Bifurcation Lesions Shih-Hung Chan1 Section of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. Chen Relevant clinical history and physical exam. A 62 year-old male with hypertension and hyperlipidemia presented with crescendo angina pectoris. Treadmill exercise test revealed positive result for myocardial ischemia. Renal function and left ventricular systolic performance are normal. Physical examination did not reveal remarkable abnormal finding. Relevant test results prior to catheterization. Treadmill exercise test: positive for myocardial ischemia Echocardiography: Adequate LV systolic performance with LVEF 64% Multi-slice coronary CTA: 1. The calcium score is 89.0 2. LM-3VD showing multifocal plaques and stenosis with a) 50-69% stenosis at distal LM b) Near 90% stenosis at dLCX c) >70% stenosis at mRCA, dRCA, pLAD, D1 branch and pLCX d) 50-69% stenosis at pRCA, mLAD and OM branch
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Relevant catheterization findings. Coronary angiography: LM:70% stenosis at dLM LAD:70% stenosis at pLAD; 90% stenosis atD1 LCX:90% stenosis at LCX orifice, 99% stenosis at dLCX, 70% stenosis at OM1 RCA: Atherosclerosis
S157
Rewired the OM1. The balloon (1.25/10) was used to open OM1 stent KBT with a balloon (3.5/15) in LCX and a balloon (2.5/15) was done 3. A Resolute Integrity stent (3.5/38) deployed at LCX A balloon(3.5/15) was used to crush LM-LCX stent. Rewiredthe LCX A balloon(2.5/15) was used to open the LM-LCX stent A NC balloon(3.5/12)was used to dilate LM-LCX stent KBT with a NC balloon(3.5/12) in LM-LCX and a balloon(3.5/15)in LM-LAD was done 4. A Resolute Integrity stent(3.5/22) was deployed at LM-pLAD. A balloon (2.5/15) used to dilate D1 A Resolute Integrity stent(2.5/26) was deployed at D1 A balloon (3.0/20) used to crush LAD-D1 stent KBT with a balloon (3.0/20) in LAD and a NC balloon(2.5/10) in D1 was done. A Resolute Integrity stent (3.0/26) deployed at LAD. Rewired the D1 KBT with a NC balloon (3.25/15) in LAD and a NC balloon (2.5/10) in D1 was done A NC balloon (3.5/12) was used to dilate pLAD 5. Rewired the LCX. KBT with a NC balloon (3.5/10)in LM-LCX and a NC balloon (3.5/12) in LM-LAD was done. Rewired the OM1. KBTwith a NC balloon (3.5/10) in pLCX and a NC balloon (2.5/10) in OM1 was done A NCballoon(4.0/8) was used to dilate LM Case Summary. In order to completely, treat the bifurcation lesions in LM/LAD/LCX, LCX/OM1, LCX/OM2, and LAD/D1 bifurcation, we chose double kissing crush two-stent technique for LM/LAD/LCX, LCX/OM1, and LAD/D1 bifurcation. Unlike the standard procedure in traditional double kissing crush technique, we performed two-stage double kissing balloon angioplasty because of the complex triple bifurcation lesion in our patient. Using our modified methods, we can finish the complex lesions without difficulty. TCTAP C-067 Kissing Balloon Technique with Drug-coated Balloons Is Effective for Repeated In-stent Restenosis at the Bifurcation of Left Anterior Descending Artery and Left Circumflex Artery Mayumi Saso,1 Yuya Tanaka,1 Yoko Kurumatani,1 Kazuyoshi Ohata1 Kofu Kyoritsu Hospital, Japan
1
[CLINICAL INFORMATION] Patient initials or identifier number. T.N Relevant clinical history and physical exam. A 90’s year-old male admitted with chest pain. His coronary risk factors were hyperlipidemia, hypertension and diabetes mellitus. He is chronic kidney failure patient (BUN 15.6 mg/dl, SCR 1.10 mg/dl, eGFR 48.0 ml/min). ECG showed normal without ST changing. Echocardiography showed a normal left ventricular ejection fraction of 60%. This case is repeated in-stent restenosis of the bifurcation of a Left anterior descending artery (LAD) and left circumflex artery (LCX). Relevant test results prior to catheterization. He underwent stenting Cypher stent 3.0 28 mm (Cordis) at proximal LAD and stenting TAXUS stent 3.0 16 mm (Boston Scientific) at proximal left main trunk (LMT) to LAD with overlapping the stent nine years ago. Because of the progressing stenosis at LCX ostium he received stent LMT-LCX with mini crush (Cypher 3.0 18 mm). After that in-stent restenosis of LCX ostium occurred several times and done balloon angioplasty with kissing balloon technique each time. Relevant catheterization findings. However, re stenosis occurred at shorter interval times. Then he underwent Excimer laser Catheter ablation for LAD and LCX and was deployed Noobori stent 4.0 13 mm (Terumo) at middle LMT to LCX ostium lesion. After the eight months, Coronary angiogram showed 90% stenosis of the proximal LAD. [INTERVENTIONAL MANAGEMENT] Procedural step. 1. A 7Fr JL4 GC was used. The LAD, LCX,and OM2 were wired. KBT with a balloon(1.25/10) in OM2 and a balloon(3.5/15) indLCX was done. 2. Wired OM1. A balloon (2.5/15) was usedto dilate OM1 A Resolute Integrity stent (2.5/18) was deployed at OM1 A balloon(3.5/15) was used to crush the OM1 stent
[INTERVENTIONAL MANAGEMENT] Procedural step. We inserted an intra-aortic balloon pumping (IABP) into the left femoral artery for hemodynamic support during the intervention. A 7Fr EBU 3.5 catheter was engaged into the left coronary ostium.(Fig.1) The LAD was wired with a 0.014 inch Sion blue and LCX was wired with a 0.014-inch Run through Hypercoat. IVUS examination showed that there was concentric soft plaque in-stent at LMT distal to LAD ostium and LCX ostium. We dilated LAD using scoring balloon ( Lacross NSE 3.5 13 mm, Goodman) 14 atm. After