BF621124

71 year-old-male with hypertension and dyslipidemia presented with progressive dyspnea on exertion within 6 months with a positive cardiac stress test. His blood pressure was 132/84 mmHg, heart rate was 84 per minute. Neither sign of heart failure nor neurological deficit. The diagnosis was chronic coronary artery syndrome.

Electrocardiogram showed normal sinus without significant ST-T abnormality.  Echocardiogram showed LVEF 65% without wall motion abnormality. No significant valvular lesion was observed. Blood tests showed no anemia, normal kidney and thyroid function.

Finding: Right dominant system. Left main coronary artery had no stenosis. Left anterior descending (LAD) artery was 30% stenosis at the ostial part, 95% stenosis at proximal part and ostial diagonal branch (DG) 1 branch (Medina 1-1-1 type). Left circumflex (LCX) was small caliber, 90 to 99% stenosis at proximal to mid part.Right coronary artery (RCA) was 90% stenosis at distal right posterolateral (RPL) branch.Diagnosis was triple vessel disease.
Media1.avi
Media2.avi
Media3.avi

The treatment plan was PCI at proximal LAD and DG 1 bifurcation lesions (Medina 1-1-1).The PCI strategic plans were about stenotic lesion preparation (lesion modification vs lesion debulking), bifurcation lesion(one-stent vs strategy vs two-stents strategy) and side branch (DG1) protection strategy (no protection vs protection) 1. Lesion preparation strategy was balloon dilatation. 2. Bifurcation PCI strategy was a provisional side branch stenting strategy.3. We needed to protect the DG1 side branch. We selected a jailed balloon technique for this case. The procedure:  Workhorse guidewires were inserted into the LAD and DG1 sequentially. Non-compliant balloon 3.5 / 15 mm was inserted into the LAD and dilated 4 atm. Drug-eluting stent 3.0 / 24 mm was inserted into LAD with semi-compliant balloon 2.0 / 20 mm to DG1 (position of proximal dot was at proximal stent part). Next, the stent was inflated at 10 atm then deflated. After that, both the LAD stent balloon and DG1 balloon were simultaneously inflated at 12 atm by using a single in-deflator with special 3-way connector. Then, DG1 balloon was removed and the stent balloon was re-inflated at 12 atm. Post dilatation at LAD stent with NC balloon 3.5 / 15 mm was done at 14 atm. Intravascular ultrasound was used before and after PCI showed good stent apposition and expansion without dissection. Final angiogram showed TIMI 3 flow of LAD and DG1.
Media4.avi
Media5.avi
Media6.avi

Coronary bifurcation lesions were 15 to 20% of PCI. Side branch (SB) occlusion after main vessel (MV) stenting was 7.4 to 8.4%, related with serious complication during PCI, stent thrombosis and cardiac death. In practice, significant SB is a branch that the operator does not want to lose after evaluating the individual patient, the length more than 73 mm represents myocardial supply more than 10%. Jailed balloon technique (JBT) is a technique aimed at improving SB protection during provisional stenting of bifurcated lesions considered at high risk of SB compromise after MV stenting. JBT is associated with high procedure success, improved SB patency and low immediate cardiac events.