Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!
TCTAP C-045
Plan B = Plan bifurcation
By Rhuban Sundran
Presenter
Rhuban Sundran
Authors
Rhuban Sundran1
Affiliation
National Heart Institute, Malaysia1,
View Study Report
TCTAP C-045
CORONARY - Bifurcation/Left Main Diseases and Intervention
Plan B = Plan bifurcation
Rhuban Sundran1
National Heart Institute, Malaysia1,
Clinical Information
Patient initials or Identifier Number
SS
Relevant Clinical History and Physical Exam
60 year old gentleman presented to our emergency department with chest pain and was diagnosed as having a NSTE-ACS. Prior to this admission he had no known medical illness and was a non-smoker but did have family history of ischaemic heart disease.
His physical examination was unremarkable and the patient was haemodynamically stable. He works as a tennis coach in the United States and was keen to return to his job. He was counselled and underwent coronary angiogram the following day.
His physical examination was unremarkable and the patient was haemodynamically stable. He works as a tennis coach in the United States and was keen to return to his job. He was counselled and underwent coronary angiogram the following day.
Relevant Test Results Prior to Catheterization
ECG:Sinus rhythm, no ST/T changes
Echocardiogram: LVEF 45% (Biplane Simpson), No significant valvular disease, Regional wall motion abnormality seen at anterior and anteroseptal regions
Blood investigation:Troponin T 1786, LDL 2.7, HbA1c 5.7%, Creatinine 77
Echocardiogram: LVEF 45% (Biplane Simpson), No significant valvular disease, Regional wall motion abnormality seen at anterior and anteroseptal regions
Blood investigation:Troponin T 1786, LDL 2.7, HbA1c 5.7%, Creatinine 77
Relevant Catheterization Findings
Coronary angiogram findings
LMS: Mild distal stenosisLAD: Moderate ostial stenosis with calcification. Severe mid segment stenosis with severe ostial D1 disease (large vessel)LCx: Dominant, mild ostial and distal diseaseRCA: Smooth
Decision made for single long stent provisional stenting from body of LMS till mid LAD while protecting diagonal branch and LCx artery.
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LMS: Mild distal stenosisLAD: Moderate ostial stenosis with calcification. Severe mid segment stenosis with severe ostial D1 disease (large vessel)LCx: Dominant, mild ostial and distal diseaseRCA: Smooth
Decision made for single long stent provisional stenting from body of LMS till mid LAD while protecting diagonal branch and LCx artery.
lad vid.avi lad2.avi lad3.aviInterventional Management
Procedural Step
Left system engaged with 6Fr EBU 3.5 via right radial. Runthrough floppy wire crossed into distal LAD, 2nd runthrough floppy placed into distal LCx and sion blue placed into diagonal 1(D1)Predilated both D1 and LAD till body of LMS with NC Scoreflex 2.5x15mm
IVUS into LAD - non-circumferential calcium with diffuse disease till distal left main stem. 3.5mm vessel proximal LAD, 4.0mm distal LMSIVUS into LCX - Mild ostial disease
Stented distal LMS till mid LAD with Synergy 3.0x38mmD1 and ostial LCx pinched
Postdilation with NC 3.5x15mm in LAD and NC 4.0x8mm in LMS. D1 rewired and kissing balloon inflation done. No improvement in pinched vessels. Bail out bifurcation stenting undertaken using reverse crush at LAD/D1 and T-stenting at LCx/LMS-LAD
Synergy 2.75x15mm used to stent D1 and crushed with a NC 3.5x12mm. Rewired D1 and postdilated with NC 3.0x15mm. Kissing balloon inflation with NC 3.0x15mm in D1 and NC 3.5x15mm in LAD followed by proximal optimization technique with high pressure NC 3.5x15mm.
LCx rewired and predilated with NC 3.0x15mm. LCx stented till the ostium with Synergy 3.0x16mm. Kissing balloon inflation with NC 3.0x12mm in LCx and NC 3.5x15mm in LAD. Proximal optimization technique with NC 4.0x8mm at LMS.
IVUS into LAD and LCx - Ostial LCx covered by stent. Both stents well opposed. No distal edge dissection. Good MSA in both vessels. Good final angiographic results with TIMI 3 flow.
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IVUS into LAD - non-circumferential calcium with diffuse disease till distal left main stem. 3.5mm vessel proximal LAD, 4.0mm distal LMSIVUS into LCX - Mild ostial disease
Stented distal LMS till mid LAD with Synergy 3.0x38mmD1 and ostial LCx pinched
Postdilation with NC 3.5x15mm in LAD and NC 4.0x8mm in LMS. D1 rewired and kissing balloon inflation done. No improvement in pinched vessels. Bail out bifurcation stenting undertaken using reverse crush at LAD/D1 and T-stenting at LCx/LMS-LAD
Synergy 2.75x15mm used to stent D1 and crushed with a NC 3.5x12mm. Rewired D1 and postdilated with NC 3.0x15mm. Kissing balloon inflation with NC 3.0x15mm in D1 and NC 3.5x15mm in LAD followed by proximal optimization technique with high pressure NC 3.5x15mm.
LCx rewired and predilated with NC 3.0x15mm. LCx stented till the ostium with Synergy 3.0x16mm. Kissing balloon inflation with NC 3.0x12mm in LCx and NC 3.5x15mm in LAD. Proximal optimization technique with NC 4.0x8mm at LMS.
IVUS into LAD and LCx - Ostial LCx covered by stent. Both stents well opposed. No distal edge dissection. Good MSA in both vessels. Good final angiographic results with TIMI 3 flow.
final1.avi final2.avi final3.aviCase Summary
This case shows the necessity to have a plan B when things do not go your way. In this case, the initial plan was to try provisional stenting but 2 large vessels were pinched in the process. Based on the angle and size, 2 different bifurcation techniques were undertaken to achieve a good final result. Lesson to take home from this case would be to consider upfront 2-stent strategy at the LAD/D1 given the size of the diagonal and its diseased ostium.
Remaining calm and understanding the steps allowed us to perform this bail out bifurcation stenting with no harm caused to the patient. He was recently seen in our follow up clinic, remains asymptomatic and is back to playing tennis.
Remaining calm and understanding the steps allowed us to perform this bail out bifurcation stenting with no harm caused to the patient. He was recently seen in our follow up clinic, remains asymptomatic and is back to playing tennis.