Double Trouble: Navigating Two Bifurcation Lesions in a Complex Intervention for Left Anterior Descending Artery Complete Occlusion
Presenter
Modar Alom, MD, Baylor Scott & White The Heart Hospital - Plano, Plano, TX
Modar Alom, MD1, Obadah Aqtash, MD2, Mohammed Salih, MD1 and Karim Al-Azizi, M.D., FSCAI3, (1)Baylor Scott & White The Heart Hospital - Plano, Plano, TX, (2)Baylor Scott & White The Heart Hospital - Plano, Dallas, TX, (3)Baylor Scott & White Health, Frisco, TX
Title:
Double the trouble: A Complex intervention of left anterior descending artery complete occlusion involving two bifurcation lesions.
Introduction
Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) stands as one of the most challenging procedures in the modern endovascular realm. Advances in interventional cardiology have spurred the development of specialized techniques and equipment tailored for CTO-PCIs. The intricacies escalate when dealing with bifurcation lesions, introducing an additional layer of complexity to CTO-PCI. In this context, we present a complex case involving left anterior descending (LAD) CTO-PCIs, where two distinct bifurcation lesions were successfully addressed using a combination of reverse controlled antegrade and retrograde tracking (CART), double kissing (DK) crush, and reverse culotte techniques. Clinical Case
A 76-year-old male patient with a medical history significant for coronary artery disease, status post redo coronary artery bypass grafting surgery with repeat interventions to his saphenous vein grafts (SVG) to the LAD and D1 (Jump graft), and ischemic cardiomyopathies, was referred to our facility for LAD CTO-PCIs due to recurrent graft restenosis and multiple non-ST-elevation myocardial infarctions. A CP Impella was inserted for hemodynamic support. The Reverse CART technique was employed to gain access to the proximal-mid LAD through the left main (LM) and SVG graft. Balloon angioplasty was performed in the proximal-mid LAD, revealing no flow in the first diagonal, with intravascular ultrasound (IVUS) confirming subintimal wire presentation. Multiple wires and microcatheters were utilized to achieve reentry into the true lumen. A bifurcation DK crush was employed for the LAD/first diagonal bifurcation, involving the placement of 2.5 x 38 mm and 3.0 x 38 mm Onyx DESs in the LAD and a 2.25 x 22 mm Onyx DES in the 1st Diagonal. The Reverse Culotte bifurcation technique was applied for the LM bifurcation, successfully placing a 3.5 x 34 mm DES from ostial LM to proximal LAD, overlapping with previous left circumflex stent. Simultaneous kissing balloon inflation was carried out using a 4.0 mm balloon in the LAD and a 3.5 mm balloon in the left circumflex artery. The LM-ostial LAD stent was post-dilated with a 5.0 mm balloon, resulting in excellent angiographic results. The procedure was free of complications. The Impella was removed, and the patient was discharged home symptom-free. Discussion
Chronic total occlusion (CTO) lesions are linked with heightened mortality and a less favorable prognosis. Despite these challenges, the outcomes of CTO percutaneous coronary intervention (PCI) have significantly improved. This progress can be attributed to the development of advanced CTO tools and algorithms, coupled with the growing expertise of operators. The field of CTO PCI is rapidly expanding, emphasizing the importance of staying on top of new technologies and guidelines.