Trifurcation Stenting with One Svelte System

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Trifurcation Stenting with One Svelte System

October 6, 2011

Courtesy of Pierfrancesco Agostoni, MD

Case Overview

A 54 year-old male patient with stable angina presented with occlusive in-stent restenosis in the LAD. In a previous procedure, a full metal jacket had been applied to the LAD. The patient was diagnosed with complex trifurcation stenosis of the left circumflex (LCX) and 1st and 2nd obtuse marginal (OM) branches (modified Medina class 0,0,1,1). (A) The challenge this lesion presented was achieving access to the OM1 branch with its very tight stenosis and acute take off.

Procedural Progression

The strategy selected was to direct stent the LCX in the direction of the OM1. Using a radial approach, a 6F guide catheter was inserted followed by placement of a BMW guidewire in the LCX as a safety wire. A Svelte Acrobat 3.5 x 13mm stent was selected and advanced across the lesion. (B)

Using the radiopaque markers on the Svelte system for guidance, the stent was positioned accurately across the lesion and deployed at 12 ATM. (C)

Control angiography showed a successful stent deployment with a sub-occluded OM2 branch. (D)

After reshaping the wire tip, the same Svelte system was used to cross through the struts of the stent to dilate the OM2 branch at 6 ATM and the LCX at 16 ATM. (E)

The Svelte system had been removed from the catheter and the safety wire was still down, so final post-dilation was completed with a non-compliant balloon (3.5×10 mm) that was advanced across the stent and inflated to 16 ATM.  Final control angio (F) showed TIMI 3 flow with a residual stenosis of 50% at the OM2 ostium.

 Conclusion

This procedure shows the versatility of the Svelte ‘All-in-One’ system. The same system was used 1) to cross the tight lesion for stent deployment and 2) to cross and post-dilate the stent struts twice, ensuring proper side branch access. This procedure could be finalized with a limited amount of additional devices: 1 guidewire, placed in the LCX and 1 non- compliant post dilatation balloon. Total procedure time from stick-to-stitch was 70 min. The final result was successful with an overall TIMI 3 flow in the LCX/OM1/OM2 vascular tree.

Keys to Success:

  • Crossability and trackability for direct stenting in complex anatomy and crossing stent struts
  • Low compliance balloon and balloon control bands for safe high-pressure post-dilation of the LCX stent.
  • Multiple inflations using the same Svelte stent system.
In this difficult trifurcation, Acrobat showed the flexibility necessary to combine time and cost savings with the ability to deliver an optimal result.

– Pierfrancesco Agostoni, MD