2019 Scientific Sessions

Title Distal left main PCI, DK-crush troubleshooting Introduction DK crush technique can be technically challenging in complex disease. We present a complex case of distal LM bifurcation DK crush stenting. Clinical Case A 71-year-old man presents with progressive exertional angina. He has history of and prior CABG with LIMA to LAD, radial graft to OM1, and radial graft to rPDA. Diagnostic angiogram showed severe distal LM disease compromising flow to LCX and LAD that was supplying 2 large diagonal branches prior to mid occlusion. An US-guided right femoral access was used. Engagement of LM with EBU 3.5 and EBU 4.0 guides failed. Engagement was successful with JL4 guide and a Sion blue guidewire was immediately used to wire the LCX through a Caravel microcatheter; and the Sion blue was exchanged for a Grand Slam Guidewire through the Caravel. An 8-Fr EBU 4.0 was exchanged over the stiff Grand Slam to engage the LM. Wiring of the LAD was difficult due to 99% distal LM stenosis along with unfavorable angulation; it was finally successful after multiple attempts using a Fielder FC guidewire and a Twin-pass dual access microcatheter. Fielder FC was exchanged for a Sion Blue through a Caravel. Multiple pre-dilation attempts were done followed by a 3.0x15 mm AngioSclupt in the LAD and LCX. We performed further LCX pre-dilation and that was complicated by LCX dissection which was immediately addressed with a 2.5x38 mm DES in the LCX post-dilated with 3.0 mm NC balloon. The LCX stent was crushed with a 3.0 NC balloon in the LAD. Rewiring of LCX stent was challenging after the first crush. We used a fielder FC to rewire the LCX stent but failed to cross with a balloon. Proximal optimization (POT) of the stent was performed followed by rewiring of the LCX stent, but with failure to cross a balloon. We used a dual-access Twin-pass microcatheter and finally rewiring was successful with a Fielder FC and a Sapphire pro 1.0 mm balloon successfully crossed. This was followed by a 2.0 mm balloon to the LCX and the first kiss was performed. The LAD was stented with a 2.75x18 mm DES. We then rewired the LCX with a Fielder FC and a final kiss was performed with final excellent angiographic result. Discussion In our case, we demonstrate the troubleshooting steps during a LM DK-crush stenting procedure. In difficult engagement, we used a diagnostic catheter to wire the LM/LCX with a grand slam and exchanged for an EBU guide over it. We used meticulous lesion preparation confirmed by IVUS. We had difficulty rewiring the side branch; and we used POT, a dual lumen microcatheter, and a polymer-jacketed wire to facilitate rewiring. We also had difficulty re-crossing with a balloon; and we used a Sapphire Pro 1.0 mm balloon to predilate and facilitate crossing with larger balloons