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Shoulder technique: A modified sleeve technique devised for treating isolated coronary stenosis at side branch ostium
94
Letters to the Editor
Shoulder technique: A modified sleeve technique devised for treating isolated coronary stenosis at side branch ostium Man-Hong Jim ⁎ Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong
a r t i c l e
i n f o
Article history: Received 21 August 2013 Accepted 25 November 2013 Available online 4 December 2013 Keywords: Percutaneous Coronary intervention Bifurcation stenoses Drug-eluting balloon
Isolated coronary stenosis at side branch (SB) ostium (MEDINA classification 0,0,1 lesion) is a treatment dilemma of which no management consensus has been reached so far, even from expert panel [1]. Complete SB ostium stent coverage without inducing much main vessel (MV) injury is the key to success. One line of approach, such as the Szabo technique [2–4], mainly focuses on the precise stent positioning at SB ostium. This technique involves special pre-treatment of stent, and has been reported to be predisposed to stent dislodgement [5]. Recently, a strategy known as BOMB [6], has been described using SB stent protrusion to fully cover the SB ostium and drug-eluting balloon kissing to maintain MV patency, as well as minimize the subsequent cellular proliferative response of MV. However, if the bifurcation angle is small, the length of the resultant pseudo-carina is long. Moreover, the proximal MV segment may be over-dilated by the kissing balloon inflation. A new strategy, named as the shoulder technique, is devised to overcome the pitfall. The isolated SB ostial stenosis (Fig. 1A) is wired and prepared by balloon dilatation. A stent is positioned in the SB with protrusion of 2– 3 mm into the MV. A protection balloon is placed concurrently in the MV. The SB stent is then deployed (Fig. 1B), followed by removal of the SB wire. The protection balloon in MV is inflated to crush the protruding SB stent segment against the MV wall (Fig. 1C). The SB is rewired through the stent strut; the lumen of the SB ostium is reopened with a balloon inflated at high pressure (Fig. 1D). Finally, the MV is dilated with a drug-eluting balloon of length longer than the protection balloon (Fig. 1E). The resultant SB stent looks like the shoulder of a sleeve (Fig. 1F). A 57-year-old gentleman who had smoking, hypertension and hyperlipidemia as the cardiovascular risk factors had an episode of acute coronary syndrome 15 months ago. At that time, coronary angiography revealed single-vessel disease, with a focal lesion of 90% diameter stenosis at the proximal left anterior descending artery (LAD). Left ventriculography showed normal cardiac function. His renal function was normal. Ad hoc intervention was performed on the proximal LAD using a drug-eluting stent. The diagonal branch was spared which had an ostial disease of 40% diameter stenosis. He presented again with class II angina, with progressive deterioration in severity. Treadmill test was abnormal, showing horizontal 1 mm ST depression in V4-6 at stage III using Bruce protocol. Coronary angiography was arranged which revealed patent proximal LAD stent, and a focal 80% diameter stenosis right at the diagonal ostium (Fig. 2A), other coronary segments were normal. This was a 0,0,1
⁎ Tel.: + 852 2518 2619; fax: +852 2518 8558. E-mail address: [email protected].
lesion by the MEDINA classification; the ratio of vessel size between the coronary segments proximal and distal to the diagonal branch was less than 1.1. Ad hoc coronary intervention was performed through right radial approach using the shoulder technique described above. Unfractionated heparin 5,500U was administered intra-arterially (80 units/kg); the resulted activated clotting time was N300 s. A 6F EBU guiding catheter was used to intubate the left main artery. The LAD and diagonal were wired with 0.014 inch soft coronary wires. A RESOLUTE 2.25 × 12 mm stent (Medtronic Incorporation, Santa Rosa, CA) was positioned in the diagonal branch with protrusion of its proximal 2 mm segment into the LAD; a 2.5 × 10 mm balloon was positioned in the LAD alongside the stent. The diagonal stent was deployed at 12 atm; the stent-balloon was deflated and removed together with the diagonal wire. The balloon in LAD was inflated at 14 atm to crush the protruding diagonal stent segment against the wall of the LAD. The diagonal was then re-wired; a 2.25 × 10 mm balloon was positioned across the diagonal ostium and inflated at 16 atm to post-dilate the stent. At the conclusion of the procedure, ELUTAX 3.0 × 15 mm (Aachen Resonance GmbH, Pauwelsstrasse, Aachen, Germany) (a drug-eluting balloon), was positioned in the LAD covering the entire treated segment, and inflated at 10 atm for 90 s. The final angiogram showed a very nice result of which the ostium of the diagonal branch looked like the shoulder of a sleeve (Fig. 2B). No postprocedure enzyme leak was observed. Restudy angiography performed at 14 weeks revealed no restenosis at the diagonal ostium (Fig. 2C). Patient remained symptom free on subsequent clinical follow-up. Since no major study has been performed on this bifurcation lesion subset, the choice of treatment is based on technical and anatomical considerations. In the Szabo technique, the stent is partially flared by the stent-balloon ex vivo, and a coronary wire is inserted through proximal second crown of stent strut. The stent is then re-crimped on the stent-balloon upon use. When the newly mounted wire is placed in the MV while the stent is delivered into the SB, the proximal stent edge is one stent strut proximal to the flow-divider. The position is ideal if the bifurcation angle is nearly 90°. The SB ostium is unlikely to be completely covered if the bifurcation angle is getting more acute. In addition, the efficacy of the technique is highly operator-dependent. In the presence of anatomical complexities, such as calcification and tortuosity, these may lead to stent dislodgement and malpositioning [5]. The BOMB strategy is an innovative and technically simple approach. It requires no SB re-cross, and is best suited for large proximal MV and relatively small distal MV and SB in light of the kissing balloon inflation at the end. However, for lesions with small (acute) bifurcation angle, the resultant pseudo-carina is long which raises a question of susceptibility to stent thrombosis. The long segment of kissing balloon inflation may over-dilate and distort the anatomy of the proximal MV segment, particularly if the vessel size is small in general. The shoulder technique is a modified version of the sleeve technique originally designed for true bifurcation lesions [7–9]. Like the BOMB strategy, it uses drug-eluting balloon to maintain the MV patency and prevent MV stenosis (Fig. 1E). The major advantage of this technique is the preservation of the natural shape of the bifurcation. The protrusion SB stent segment allows complete SB ostium coverage, whereas the hanging stent segment is pressed against the MV wall by balloon, conforming to the shape and curvature of the vessel (Fig. 1C),
Letters to the Editor
95
Fig. 1. Schematic diagram showing the outline of the shoulder technique. (A) Isolated coronary stenosis at the SB ostium. (B) Positioning of SB stent with proximal protrusion into the MV; a protection balloon is placed in the MV concurrently. (C) After deployment of the SB stent, the MV protection balloon is inflated to crush the protruding SB stent segment against the MV wall. (D) After rewiring of the SB, the SB ostium is dilated with a balloon. (E) A drug-eluting balloon, as indicated by shaded balloon, is inflated in the MV. (F) The final result shows a nice stent sleeve at the SB.
Fig. 2. Coronary angiogram showed (A) a focal severe stenosis at the ostium of the diagonal branch. (B) At the conclusion of the shoulder technique, the diagonal ostium looked like the shoulder of a sleeve. (C) Restudy angiogram at 14 weeks showed no restenosis.
with no pseudo-carina or proximal MV over-dilatation created (Fig. 1F). The angiographic result is independent of the bifurcation angle. The shape of the lumen is elliptical at SB ostium, with its longitudinal diameter larger than the body of the SB. The discrepancy widens with smaller bifurcation angle. A larger balloon (compared with the SB stent) may be required to open up the SB ostium to achieve a better stent size and expansion (Fig. 1D). The technique is most suitable for MEDINA 0,0,1 lesion with similar sub-segment sizes (proximal MV ≈ distal MV ≈ SB) and small bifurcation angle. The shoulder technique and the BOMB strategy are indeed, complementary to each other in the management of this bifurcation lesion subtype. Registry of larger size is needed to prove the long-term efficacy, in terms of clinical and angiographic outcomes, of this technique. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International of Journal of Cardiology. References [1] Hildick-Smith D, Lassen JF, Albiero R, et al. European Bifurcation Club. Consensus from the 5th Bifurcation Club Meeting. EuroIntervention 2010;6:34–8.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.076
[2] Applegate RJ, Davis JM, Leonard JC. Treatment of ostial lesions using the Szabo technique: a case series. Catheter Cardiovasc Interv 2008;72:823–8. [3] Kern MJ, Ouellette D, Frianeza T. A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique. Catheter Cardiovasc Interv 2006;68:901–6. [4] Gutiérrez-Chico JL, Villanueva-Benito I, Villanueva-Montoto L, et al. Szabo technique versus conventional angiographic placement in bifurcations 010-001 of Medina and in aorto-ostial stenting: angiographic and procedural results. EuroIntervention 2010;5:801–8. [5] Ferrer-Gracia MC, Sánchez-Rubio J, Calvo-Cebollero I. Stent dislodgement during Szabo technique. Int J Cardiol 2011;147:e8–9. [6] Jim MH. Side branch ostium stenting with main vessel drug-eluting balloon kissing (BOMB): an innovative approach for isolated coronary stenosis at side branch ostium. Int J Cardiol 2013;168:4939–40. [7] Jim MH, Ho HH, Miu R, Chow WH. Modified crush technique with double kissing balloon inflation (sleeve technique): A novel technique for coronary bifurcation lesions. Catheter Cardiovasc Interv 2006;67:403–9. [8] Jim MH, Ho HH, Ko RL, Siu CW, Yiu KH, Chow WH. Long-term clinical and angiographic outcomes of the sleeve technique on non-left-main coronary bifurcation lesions. EuroIntervention 2009;5:104–8. [9] Jim MH, Ho HH, Yiu KH, Siu CW, Chow WH. Angiographic and long-term clinical outcome of the sleeve technique in treating in-stent restenotic bifurcation lesions: a preliminary experience. Acute Card Care 2011;13:159–63.
Letters to the Editor
Shoulder technique: A modified sleeve technique devised for treating isolated coronary stenosis at side branch ostium Man-Hong Jim ⁎ Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong
a r t i c l e
i n f o
Article history: Received 21 August 2013 Accepted 25 November 2013 Available online 4 December 2013 Keywords: Percutaneous Coronary intervention Bifurcation stenoses Drug-eluting balloon
Isolated coronary stenosis at side branch (SB) ostium (MEDINA classification 0,0,1 lesion) is a treatment dilemma of which no management consensus has been reached so far, even from expert panel [1]. Complete SB ostium stent coverage without inducing much main vessel (MV) injury is the key to success. One line of approach, such as the Szabo technique [2–4], mainly focuses on the precise stent positioning at SB ostium. This technique involves special pre-treatment of stent, and has been reported to be predisposed to stent dislodgement [5]. Recently, a strategy known as BOMB [6], has been described using SB stent protrusion to fully cover the SB ostium and drug-eluting balloon kissing to maintain MV patency, as well as minimize the subsequent cellular proliferative response of MV. However, if the bifurcation angle is small, the length of the resultant pseudo-carina is long. Moreover, the proximal MV segment may be over-dilated by the kissing balloon inflation. A new strategy, named as the shoulder technique, is devised to overcome the pitfall. The isolated SB ostial stenosis (Fig. 1A) is wired and prepared by balloon dilatation. A stent is positioned in the SB with protrusion of 2– 3 mm into the MV. A protection balloon is placed concurrently in the MV. The SB stent is then deployed (Fig. 1B), followed by removal of the SB wire. The protection balloon in MV is inflated to crush the protruding SB stent segment against the MV wall (Fig. 1C). The SB is rewired through the stent strut; the lumen of the SB ostium is reopened with a balloon inflated at high pressure (Fig. 1D). Finally, the MV is dilated with a drug-eluting balloon of length longer than the protection balloon (Fig. 1E). The resultant SB stent looks like the shoulder of a sleeve (Fig. 1F). A 57-year-old gentleman who had smoking, hypertension and hyperlipidemia as the cardiovascular risk factors had an episode of acute coronary syndrome 15 months ago. At that time, coronary angiography revealed single-vessel disease, with a focal lesion of 90% diameter stenosis at the proximal left anterior descending artery (LAD). Left ventriculography showed normal cardiac function. His renal function was normal. Ad hoc intervention was performed on the proximal LAD using a drug-eluting stent. The diagonal branch was spared which had an ostial disease of 40% diameter stenosis. He presented again with class II angina, with progressive deterioration in severity. Treadmill test was abnormal, showing horizontal 1 mm ST depression in V4-6 at stage III using Bruce protocol. Coronary angiography was arranged which revealed patent proximal LAD stent, and a focal 80% diameter stenosis right at the diagonal ostium (Fig. 2A), other coronary segments were normal. This was a 0,0,1
⁎ Tel.: + 852 2518 2619; fax: +852 2518 8558. E-mail address: [email protected].
lesion by the MEDINA classification; the ratio of vessel size between the coronary segments proximal and distal to the diagonal branch was less than 1.1. Ad hoc coronary intervention was performed through right radial approach using the shoulder technique described above. Unfractionated heparin 5,500U was administered intra-arterially (80 units/kg); the resulted activated clotting time was N300 s. A 6F EBU guiding catheter was used to intubate the left main artery. The LAD and diagonal were wired with 0.014 inch soft coronary wires. A RESOLUTE 2.25 × 12 mm stent (Medtronic Incorporation, Santa Rosa, CA) was positioned in the diagonal branch with protrusion of its proximal 2 mm segment into the LAD; a 2.5 × 10 mm balloon was positioned in the LAD alongside the stent. The diagonal stent was deployed at 12 atm; the stent-balloon was deflated and removed together with the diagonal wire. The balloon in LAD was inflated at 14 atm to crush the protruding diagonal stent segment against the wall of the LAD. The diagonal was then re-wired; a 2.25 × 10 mm balloon was positioned across the diagonal ostium and inflated at 16 atm to post-dilate the stent. At the conclusion of the procedure, ELUTAX 3.0 × 15 mm (Aachen Resonance GmbH, Pauwelsstrasse, Aachen, Germany) (a drug-eluting balloon), was positioned in the LAD covering the entire treated segment, and inflated at 10 atm for 90 s. The final angiogram showed a very nice result of which the ostium of the diagonal branch looked like the shoulder of a sleeve (Fig. 2B). No postprocedure enzyme leak was observed. Restudy angiography performed at 14 weeks revealed no restenosis at the diagonal ostium (Fig. 2C). Patient remained symptom free on subsequent clinical follow-up. Since no major study has been performed on this bifurcation lesion subset, the choice of treatment is based on technical and anatomical considerations. In the Szabo technique, the stent is partially flared by the stent-balloon ex vivo, and a coronary wire is inserted through proximal second crown of stent strut. The stent is then re-crimped on the stent-balloon upon use. When the newly mounted wire is placed in the MV while the stent is delivered into the SB, the proximal stent edge is one stent strut proximal to the flow-divider. The position is ideal if the bifurcation angle is nearly 90°. The SB ostium is unlikely to be completely covered if the bifurcation angle is getting more acute. In addition, the efficacy of the technique is highly operator-dependent. In the presence of anatomical complexities, such as calcification and tortuosity, these may lead to stent dislodgement and malpositioning [5]. The BOMB strategy is an innovative and technically simple approach. It requires no SB re-cross, and is best suited for large proximal MV and relatively small distal MV and SB in light of the kissing balloon inflation at the end. However, for lesions with small (acute) bifurcation angle, the resultant pseudo-carina is long which raises a question of susceptibility to stent thrombosis. The long segment of kissing balloon inflation may over-dilate and distort the anatomy of the proximal MV segment, particularly if the vessel size is small in general. The shoulder technique is a modified version of the sleeve technique originally designed for true bifurcation lesions [7–9]. Like the BOMB strategy, it uses drug-eluting balloon to maintain the MV patency and prevent MV stenosis (Fig. 1E). The major advantage of this technique is the preservation of the natural shape of the bifurcation. The protrusion SB stent segment allows complete SB ostium coverage, whereas the hanging stent segment is pressed against the MV wall by balloon, conforming to the shape and curvature of the vessel (Fig. 1C),
Letters to the Editor
95
Fig. 1. Schematic diagram showing the outline of the shoulder technique. (A) Isolated coronary stenosis at the SB ostium. (B) Positioning of SB stent with proximal protrusion into the MV; a protection balloon is placed in the MV concurrently. (C) After deployment of the SB stent, the MV protection balloon is inflated to crush the protruding SB stent segment against the MV wall. (D) After rewiring of the SB, the SB ostium is dilated with a balloon. (E) A drug-eluting balloon, as indicated by shaded balloon, is inflated in the MV. (F) The final result shows a nice stent sleeve at the SB.
Fig. 2. Coronary angiogram showed (A) a focal severe stenosis at the ostium of the diagonal branch. (B) At the conclusion of the shoulder technique, the diagonal ostium looked like the shoulder of a sleeve. (C) Restudy angiogram at 14 weeks showed no restenosis.
with no pseudo-carina or proximal MV over-dilatation created (Fig. 1F). The angiographic result is independent of the bifurcation angle. The shape of the lumen is elliptical at SB ostium, with its longitudinal diameter larger than the body of the SB. The discrepancy widens with smaller bifurcation angle. A larger balloon (compared with the SB stent) may be required to open up the SB ostium to achieve a better stent size and expansion (Fig. 1D). The technique is most suitable for MEDINA 0,0,1 lesion with similar sub-segment sizes (proximal MV ≈ distal MV ≈ SB) and small bifurcation angle. The shoulder technique and the BOMB strategy are indeed, complementary to each other in the management of this bifurcation lesion subtype. Registry of larger size is needed to prove the long-term efficacy, in terms of clinical and angiographic outcomes, of this technique. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International of Journal of Cardiology. References [1] Hildick-Smith D, Lassen JF, Albiero R, et al. European Bifurcation Club. Consensus from the 5th Bifurcation Club Meeting. EuroIntervention 2010;6:34–8.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.11.076
[2] Applegate RJ, Davis JM, Leonard JC. Treatment of ostial lesions using the Szabo technique: a case series. Catheter Cardiovasc Interv 2008;72:823–8. [3] Kern MJ, Ouellette D, Frianeza T. A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique. Catheter Cardiovasc Interv 2006;68:901–6. [4] Gutiérrez-Chico JL, Villanueva-Benito I, Villanueva-Montoto L, et al. Szabo technique versus conventional angiographic placement in bifurcations 010-001 of Medina and in aorto-ostial stenting: angiographic and procedural results. EuroIntervention 2010;5:801–8. [5] Ferrer-Gracia MC, Sánchez-Rubio J, Calvo-Cebollero I. Stent dislodgement during Szabo technique. Int J Cardiol 2011;147:e8–9. [6] Jim MH. Side branch ostium stenting with main vessel drug-eluting balloon kissing (BOMB): an innovative approach for isolated coronary stenosis at side branch ostium. Int J Cardiol 2013;168:4939–40. [7] Jim MH, Ho HH, Miu R, Chow WH. Modified crush technique with double kissing balloon inflation (sleeve technique): A novel technique for coronary bifurcation lesions. Catheter Cardiovasc Interv 2006;67:403–9. [8] Jim MH, Ho HH, Ko RL, Siu CW, Yiu KH, Chow WH. Long-term clinical and angiographic outcomes of the sleeve technique on non-left-main coronary bifurcation lesions. EuroIntervention 2009;5:104–8. [9] Jim MH, Ho HH, Yiu KH, Siu CW, Chow WH. Angiographic and long-term clinical outcome of the sleeve technique in treating in-stent restenotic bifurcation lesions: a preliminary experience. Acute Card Care 2011;13:159–63.