Go Radial for Sequential SKS and V Stenting
Presenter
Priyanka Ghosh, DO, Guthrie Robert Packer Hospital, McKees Rocks, PA
Priyanka Ghosh, DO, Guthrie Robert Packer Hospital, McKees Rocks, PA, Amit Chandravadan Shah, DO, FSCAI, NYU Langone Medical Center, Brooklyn, NY and Edo Kaluski, M.D., FSCAI, Guthrie Robert Packer Hospital, Sayre, PA
Title:
Go Radial for Sequential SKS and V-Stenting
Introduction:
Conventional teaching of simultaneous kissing stents (SKS) and V-stenting (VS) techniques mandate the use of 8 French guiding catheters. SKS and VS techniques differ in the length of proximal overlap between the “kissing bifurcation stents”: where SKS has > 5 millimeters (mm) overlap, VS has ≤ 5 mm of overlap. With the widespread adoption of wrist-based percutaneous coronary intervention (PCI) these 2-stent techniques have been abandoned in favor of “upfront 2-stent” strategies compatible with 6F guiding catheters. This case details a “sequential SKS and VS” method which can be executed via conventional 6F guiding catheter.
Clinical Case:
76-year-old male with prior coronary stenting to the left anterior descending artery (LAD), one-vessel coronary artery bypass grafting (CABG) with a saphenous vein graft (SVG) to the right coronary artery (RCA) and aortic valve replacement presented with unstable angina. Cardiac catherization demonstrated occluded SVG, distal left main bifurcation stenosis and triple vessel disease and he was referred from another facility for CABG. After discussion among the “heart team” (since the patient was deemed a high surgical risk) and joint decision with the patient, he was referred for PCI. Right radial access was used employing a 6F EBU 3.5 guide. DFR (diastolic hyperemia-free ratio) confirmed stenosis severity in both the LAD, circumflex, and distal left main coronary artery (LMCA). Significant lesions downstream to the bifurcation were treated first including a mid-LAD focal instent restenotic lesion. “Sequential V-stenting” was chosen for the distal LMCA bifurcation (Medina 1,1,1). After pre-dilatation of the proximal LAD and circumflex with non-compliant balloons, the circumflex stent was appropriately positioned with concurrent placement of a balloon in the LAD. The circumflex stent was deployed and after stent balloon deflation, the LAD balloon was pulled back with 4-5 mm overlap with the circumflex stent, followed by simultaneous inflation and deflation of the circumflex stent balloon and LAD balloon. After removal of the LAD balloon and the circumflex stent-balloon, a stent was advanced to the proximal LAD and a balloon was positioned in the proximal portion of the circumflex stent with 4-5 mm overlap. Simultaneous high-pressure inflation and deflation was done of the LAD stent and the circumflex balloon. Post-PCI coronary angiography demonstrated successful stenting and TIMI (Thrombolysis in Myocardial Infarction) 3 flow.
Discussion:
While conventional SKS and VS require 8F guiding catheters and are not compatible with conventional 6F radial access; “sequential SKS and VS” is a novel method compatible with 6F guiding catheters. This strategy is simple, fast and predictable and is especially attractive for acute coronary syndromes and hemodynamically vulnerable subjects. It also provides excellent immediate and long-term access to the downstream vessels. Interventional cardiologists should be familiar and comfortable with the “sequential VS and SKS” technique.