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Case 13: Calcified Prox LAD and Angulated Diagonal Bifurcation Intervention

Case Presentation

  • A 71-year-old man presented with new onset CCC class III angina and found to have positive exercise EKG stress test with significant ST-segment depression in multiple leads.
  • PMH: HTN, Ex-smoker
  • Medications : ASA 81mg, Clopidogrel 75mg, Metoprolol XL 50mg, Isosorbide mononitrate 30mg, Atorvastatin 20mg
  • Coronary angiogram showed calcific 3V CAD; 80% calcified prox-mid RCA, 90% calcified prox LAD with angulated diagonal bifurcation, and small sized 80% LCx-LPL1
  • Syntax score 24 , LVEF 65%
  • He was planned to undergo PCI of LAD and angulated diagonal bifurcation.

Angiogram

PCI Strategy

  • 7F VL guide system
  • Upfront two stents strategy
  • May need lesion modification (Atherectomy) in LAD
  • Workhorse wire in LAD (i.e. Runthrough wire)
  • Probably require an angulated catheter to wire a severely angulated diagonal branch

Case Planning

Venture Catheter

STEPS

  • Atherectomy of LAD was performed by using Orbital atherectomy.
  • Venture catheter was used to wire the side branch but it was unsuccessful.
  • Then proximal optimization and PTCA of LAD with 3.0 balloon was done.

STEPS

  • Supercross 120 microcatheter with 300cm Runthrough wire was successfully navigated into the side branch.
  • Runthrough wire was used here to wire the side branch as Fielder went into the subintimal.
  • Two stents approach by using Mini Crush technique was done (30/12mm in LAD and 2.5/28mm in diagonal branch) followed by serial balloon dilatation and kissing balloon inflation.

Wiring Diagonal Branch (Supercross 120 + Runthrough)

Bifurcation Technique

The various bifurcation stenting techniques can be reviewed in the BifurcAID app (Apple App store / Google Play store)
Or the new fully 3D-animated BifurcAID 3D app:
Web App: www.CardiologyApps.com/BifurcAID-3D
Mobile App: (Apple App store / Google Play store)

Final Angiogram

Learning Points

  • The wire choice for bifurcation lesion is a regular workhorse wire in the main branch and polymer coated wire in a side branch to minimize the risk of wire retrieval damage.
  • The operator used Runthrough in diagonal branch wiring as Fielder wire went into subintimal.
  • The angulated microcatheter (Supercross, Venture) is especially useful to navigate in a severely angulated side branch and aneurysm lesion.
  • The operator’s choice of bifurcation stenting method is mini crush technique. This and other techniques can be reviewed on the BifurcAID app.

Left Main DK Crush Video ID