Triple Bifurcation Stenting for Complete Revascularization of a Patient With NSTEMI
Madeline Mahowald, MD, FSCAI, University of Florida College of Medicine Jacksonville, Jacksonville Beach, FL
Madeline Mahowald, MD, FSCAI, University of Florida College of Medicine Jacksonville, Jacksonville Beach, FL
Title:
Triple Bifurcation Stenting for Complete Revascularization of a Patient with NSTEMI
Introduction:
Coronary bifurcation lesions can be challenging to treat and can benefit from a structured, algorithmic approach. We present a case that required treatment of 3 bifurcation lesions to achieve complete revascularization.
Clinical Case:
An 81-year-old man presented locally for chest pain and was diagnosed with a non-ST-elevation myocardial infarction. He was transferred to our institution for urgent coronary angiography, which revealed a 90% distal left main lesion extending into the proximal left anterior descending (LAD) and proximal left circumflex arteries with TIMI 2 flow. Additionally, there was a 70% lesion in the mid-LAD at the bifurcation of the first diagonal and a 70% lesion of the proximal circumflex at the take-off of the first obtuse marginal. Intravascular ultrasound was used to delineate the extent of the lesions. The patient was turned down for surgery and proceeded to percutaneous coronary intervention. Due to elevated left ventricular filling pressures, an Impella CP device was placed prior to successful intervention of the distal left main with a DK crush strategy, LAD-diagonal with a DK crush strategy, and circumflex with a provisional one-stent strategy. There were no procedural complications, but the patient did require intubation for management of agitation and hypertension.
Discussion:
Although ad hoc left main percutaneous coronary intervention is not routinely advised, it can be successfully performed with well-prepared multi-disciplinary teams. An algorithmic approach to bifurcation stenting can guide the operator in choosing the most appropriate technique for different lesion subsets; intravascular imaging is essential to procedural planning. Patient acuity and hemodynamics are also important to consider, especially when the aim of complete revascularization requires complex multivessel stenting.