Case 2: A Couple of Bifurcations
Presenter
Megha Prasad, M.D., Columbia Univeristy Medical Center, New York, NY
Megha Prasad, M.D., Columbia Univeristy Medical Center, New York, NY
Title Bail-Out TAP (T & Protrusion) Technique During Provisional Stenting Strategy In Non-Complex Bifurcation PCI: Importance Of Balloon Blocking And Support Technique (BBST) Introduction Despite advancements in the devices and techniques used for percutaneous coronary intervention, side branch (SB) wiring remains highly challenging in certain bifurcation intervention cases which are supposed to be non-complex (by definition) to begin with. Non-complex bifurcation lesions (1,1,0) or (1,0,0) may turn into complex scenarios after stenting of the main branch (MB). Complex bifurcation situation occurs for two reasons. Stenting of MB helps to grow the SB (>2 mm) and makes it important vessel which had remained smaller before. Stenting of MB also shifts the plaque distally into MB and also into SB extending >5 mm into ostium with ‘snow-plough’ effect. TAP technique helps to tackle the SB swiftly. Pullback wiring along with balloon pinning technique (modified BBST) may help to facilitate the SB wiring. Clinical Case 60/M had suffered inferior wall MI 3 – 4 years ago. Currently, he presented with stable angina, NYHA Class III. Heart rate 80 / minute. BP 130/80 mm Hg. Body surface area 1.8 square metre. Body mass index 28. Hemoglobin 14 gm. Electrocardiogram – Old inferior wall MI. 2D Echocardiography – Inferior wall scar. LVEF- 35%. Treadmill test - Positive. Thallium scan showed reversible ischaemia in LAD territory. PET scan revealed non- viability in RCA territory. Rest of the myocardium remained viable. CAG - LM normal. LAD – type III vessel with 90% bifurcation lesion after ostium. D1 – moderate sized vessel with minor plaque at ostium. LCX – Normal. RCA – CTO with grade III collaterals. PCI with provisional stenting strategy to LAD bifurcation was performed. BMW and Sion blue wires were advanced into LAD and D1 respectively. LAD lesion was predilated with 2 x 10 mm balloon. Provisional stenting with 3.5 x 20 mm was performed @ 14 atms. D1 showed no-reflow. Patient had angina, ST/T changes along with compromised hemodynamics. POT – LAD stent performed. It proved very difficult to re-enter right angled SB. Pull-back / reverse wire technique used to re-enter SB along with balloon pinning (modified BBST) technique. Balloon pinning comprises inflation of a small sized balloon at the carina in the MB to facilitate wire access to the SB. SB was dilated. 2.25 x 24 stent was deployed with TAP technique. FKBT and Re-POT were performed. F/U TMT at 6 months remained negative. Discussion Non-complex bifurcation may turn into complex scenario with major plaque-shift into SB, which is (ie: SB) also previously underestimated in size prior to MB stenting. Perpendicular angle may compromise SB (against popular belief). Reverse wire technique is helpful in bifurcation PCI with perpendicular angle. Balloon pinning (partial anchoring) along with BBST can be utilised to rewire angled SB which also may act as a microcatheter like support. TAP (Default bail – out strategy) is better and swift / simple / safe technique than crush or culotte in such situations. In retrospect, upfront 2 stent strategy could have been better in this case.