Bifurcation Stenting with Kissing Technique via TRI

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Bifurcation Stenting with Kissing Technique via TRI

September 20, 2011

Courtesy of Stefan Verheye, MD, PhD, Middelheim Hospital, Antwerp, Belgium

Case Overview

A 69-year old patient presented with stable angina. Coronary angiography showed a Medina class 0,1,1 bifurcation lesion in the left anterior descending (LAD) artery and the first diagonal (Dg1) branch. The complexity of this lesion (ACC/AHH Class B2) was defined by the presence of tortuosity, angulation, bifurcation and calcification.

Procedural Progression

Given the low angle of the bifurcation, the strategy selected was to apply the Culotte technique and direct stent the LAD followed by direct stenting the Dg1 through the struts of the LAD stent. To ensure full wall coverage, a kissing balloon technique was used.

A 6F XB guiding catheter was inserted through the right radial artery. A 3.0 x 18 mm Svelte IDS was selected and positioned across the main branch lesion.

The Svelte stent was deployed to 16 ATM, completing the first step of the Culotte technique. Control angiography shows a nice result in the LAD with plaque shift to the Dg1 .

A second Svelte IDS (2.5 x 13 mm) was advanced to the LAD proximal to the bifurcation. The system easily crossed the struts of the previously deployed stent into the Dg1 and was optimally positioned and deployed at 14 ATM.

Keeping the Svelte IDS positioned in the Dg1, a 0.014” guidewire was inserted in the LAD.  A short 3.0 x 15 mm non-compliant balloon was positioned in the proximal part of the main branch stent. A final kissing balloon inflation was applied at 16 ATM in both branches .

Final control angiography showed a successful bifurcation stenting procedure with final TIMI 3 flow in both vessels .

Conclusion

This procedure demonstrates the versatility of the Svelte IDS in bifurcation lesions treated via Culotte technique.  The first IDS was used to cross the tortuous lesion and direct stent the main branch.  A second IDS crossed through the struts of the main branch stent and was successfully deployed. The same second IDS was used to perform the kissing balloon technique. The procedure was finalized with a limited amount of additional devices: 1 guide wire and 1 non-compliant post dilatation balloon to employ the kissing balloon technique. The final result was successful with an overall TIMI 3 flow in the LAD/Dg1 vascular tree.

Keys to Success with the IDS:

  • Excellent deliverability facilitates direct stenting even in complex anatomy
  • Ultra-low profile allows side branch access through the undilated main branch stent struts
  • Low-compliant balloon with Balloon Control Bands allows high-pressure dilatation for final kissing post-dilatation
In retrospect, one could have performed the procedure by using only 2 Svelte IDS, one in each branch, even for final kissing.

– Stefan Verheye, MD, PhD