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Intracoronary Stenting with Crushing in Coronary Artery Bifurcation Lesions

2016-04-01 / Categories:arterial, hemostasis,
  
The treatment of complex stenoses involving coronary vessel bifurcations is a challenge for invasive cardiology. Various techniques have been developed since the technique of coronary angioplasty was first applied.1,2 The introduction of intracoronary stents into everyday clinical practice led to a significant increase in the number of successful treatments of coronary stenoses involving bifurcated vessels. A variety of techniques have been developed that use stents either only in the main branch or in both branches.3-6 In spite of this, the restenosis rate, even with the use of stents, continues to be high, especially in the branch.7 This, of course, depends on the technique that is used. In the last two years drugeluting stents have made their mark in the field of invasive cardiology, reducing restenosis rates by a significant degree.8-10 In this study we report our experience from the use of the crushing technique in 24 patients, we describe the initial angiographic results and the findings from medium-term follow up.

Methods

In the crushing technique the dilation of the stent in the secondary branch is carried out with the proximal section of the stent within the lumen of the main branch, to ensure that it covers the ostium of the secondary branch (Figures 1, 2a, 2b, 3). Once the balloon and guide wire have been withdrawn from the stent in the secondary branch the stent in the main branch is dilated, crushing the struts of the secondary stent against the wall of the main vessel (Figures 4, 5). Thus 3 rows of metallic struts are created on the wall of the main vessel at the point where the secondary branch originates. Subsequently, if feasible, the guide wire and balloon are reintroduced into the secondary branch and a kissing balloon technique is performed simultaneously in the stents of the main and secondary branches (Figures 6a-g). The procedure is carried out under complete antiplatelet treatment and with the administration of the special antiplatelet agent reopro. The above technique was used in 24 patients (21 men, 3 women, mean age 61 ± 2.9 years). Eighteen percent of the patients had diabetes and 9% had a low ejection fraction.

Technical details

The stenosis involved a bifurcation of the left anterior descending (LAD) and diagonal (Dg) branches in 13 patients and the circumflex artery (Cx) and obtuse marginal (Om) branch in 11. Additional angioplasty in another vessel was performed in 10 patients. A total of 53 stents were implanted (2.2 stents/patient). Rapamycin-coated stents (Cypher, CORDIS) were implanted in 22 patients, while paclitaxel-coated stents (Taxus, BOSTON Scientific) were used in 2. The mean length of the stents was 24.75 ± 4.6 mm in the main vessel and 17.6 ± 3.26 mm in the branch. The mean stent diameter was 3.2 ± 0.6 mm in the main vessel and 2.7 ± 0.5 mm in the branch. In all patients balloon predilatation was performed in both vessels. Reintroduction of the guide wire into the branch with application of the kissing balloon technique was achieved in 5 patients.