Title
Modified DK crush technique for LM trifurcation lesions.
Introduction
In most cases, the left main coronary artery (LM) bifurcates into a left anterior descending artery (LAD) and a left circumflex artery (LCx). However, around 20% of the time, the LM trifurcates into an LAD, LCx and a third branch, known as ramus intermedius (RI).
1 Obstructive coronary artery disease (CAD) with atherosclerotic lesions involving the LM trifurcation represents a revascularization challenge. In patients with LM disease of low or intermediate anatomical complexity, the EXCEL trial showed no significant difference between PCI and CABG in terms of the rate of death, stroke, or myocardial infarction at 5 years. Low or intermediate anatomical complexity was defined as a SYTNAX score of 32 or less.
2 We describe a modified DK crush technique that was used for high risk PCI of left main trifurcation lesions.
Clinical Case
A 67-year-old ex-smoker (40 pack years) male patient with past medical history significant for hypertension and dyslipidemia presented to the emergency room complaining of exertional angina and dyspnea. His symptoms had started 6 months prior to presentation, with recent acceleration over 1 week. EKG revealed normal sinus rhythm with nonspecific ST-T wave changes in the inferior and lateral leads. Serial high-sensitivity troponin I ruled out acute coronary syndrome. Transthoracic echocardiogram showed left ventricular ejection fraction of 57%, with grade 1 diastolic dysfunction and septal hypokinesis. Coronary angiography revealed a left dominant circulation with multivessel disease. The left main coronary artery trifurcates into an LAD with chronic total occlusion (CTO), an LCx with proximal CTO, and an RI with a proximal 70% ulcerative stenotic lesion. Both the LAD and LCx filled retrogradely via collaterals from the RI. After discussion with the cardiology and cardiothoracic surgery teams, and consideration of the involved risk and benefit of different revascularization strategies, the patient declined coronary artery bypass grafting (CABG) and elected to pursue high risk PCI. The implemented technique involved the initial stenting of the LAD with a 3.5 x 30 mm drug-eluting stent (DES), stenting of the LCx with a 3 x 26 mm DES. A 4x20 noncompliant balloon in the RI was used to achieve the first crushing of the LAD and LCx stents. Then, the first triple kissing was performed with a 4 x 20 mm balloon at the RI, 3.5 x 30 mm balloon in the LAD, and a 3.25 x 25 mm balloon in the LCx. The distal LM-proximal RI was then stented with a 4 x 30 mm DES. The first proximal optimization was then performed using a 6 x 12 mm noncompliant balloon. This was followed by second triple kissing and proximal optimization. Post interventional coronary angiography showed TIMI-3 flow. Coronary angiography at 1 year showed patent trifurcation stents.
Discussion
Revascularization of left main trifurcation lesions remain a technical challenge. The described modified DK crush technique is a potentially durable option for left main trifurcation yet needs to be further studied. Approach and technique should be tailored to suit the coronary anatomy of individual patients.