Select Page
  1. Home
  2. Guidewire Cases
  3. Case 13: Calcified Prox LAD and Angulated Diagonal Bifurcation Intervention

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.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

Left Main DK Crush Video ID