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)
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.
