Bifurcation PCI -- KISS
A 52-year-old diabetic male presented with unstable angina. His risk factors included type II diabetes mellitus, hyperlipidemia, and tobacco use. He had undergone previous coronary bypass and had a patent mammary bypass and right coronary artery saphenous vein bypass. Previous Myoview stress test showed a large amount of lateral ischemia with maintained LV function (ejection fraction 63%). The patient had a tight calcific left main and proximal circumflex stenosis. Previous intervention was unsuccessful in recanalizing the left main and circumflex lesions adequate enough for placement of coronary stents. He presented for intervention with continued angina.
Recent data suggest that the Impella device allows one to more adequately atherectomize a long residual stenosis compared to simple intra-aortic balloon pump.1For this reason, we placed a J4 guide and the Impella device was placed via the contralateral groin. A wire was placed to protect the LAD even though it had been bypassed with an internal mammary bypass graft.
The patient presented 48 hours later with recurrence of angina. Because the concern was that we needed to do bifurcation intervention, the question of whether or not we should use the crush technique, double stenting technique, etc., came about.
Recently published papers suggest that a simple strategy is the wisest.2In fact, the simple strategy is more likely to result in less utilization of contrast, fluoroscopy with greater efficacy compared to complex techniques. Since it is unlikely we will have to place bifurcation balloons or stents, the radial technique using a 6 Fr catheter is ideal. We see the circumflex is widely patent and there appears to be 2 focal stenoses in the LAD, but again we were still concerned that we could inhibit competitive flow of the internal mammary by placing a stent.
This case demonstrated the utility of the Impella device for complete revascularization of a calcific functional occlusion, as well as using a simple strategy for a bifurcation lesion keeping into account the possibility of competitive filling of previously placed bypass grafts. The day after the procedure, the patient was discharged and continues to be asymptomatic 8 months after the procedure.
The simple bifurcation strategy again reiterates the safety and benefit of the radial approach for even complex interventions. Now that we know that the philosophy is to utilize the KISS technique, “keep it simple, stupid,” with bifurcation lesions, the radial technique is even more attractive.
Figure 3. A Miracle 3 wire (Abbott Vascular) was placed in the circumflex and a Cougar wire (Medtronic) in the left anterior descending. A .9 Spectranetics laser probe passed across the circumflex stenosis and the AngioSculpt balloon further dilated the lesion. A second 2.5 mm AngioSculpt balloon was used in the LAD proximal stenosis.
Figure 4. Shows excellent results after laser and AngioSculpt dilation and subsequent placement of a 3.5mm Xience stent (Abbott). A second 2.5 mm AngioSculpt balloon was used to post dilate the LAD after recanalization of the circumflex.
Figure 5. This RAO view shows there is some diffuse distal circumflex disease, but the proximal vessel appears to be adequately dilated. The LAD, which again has an internal mammary, is patent. We did not place a stent at the origin of the LAD because of the possibility of competitive flow from the internal mammary artery.
Figure 9. In this LAO view, we see a residual ostial stenosis of perhaps 20% in the LAD, the widely patent circumflex and a tight stenosis in the LAD distal to the take-off of a large diagonal and septal branch. This stenosis in the LAD is revascularized by the internal mammary artery and most likely will not result in competitive filling with a possibility of compromise of this excellent graft.
1O’Neill W, Kleiman N, Henriques J, et al. PROTECT II, Prospective Multicenter Randomized Trial Comparing IMPELLA to IABP in High Risk PCI: 90 Day Results, on behalf of all PROTECT II Investigators. Presented at SCAI 2011.
2Behan M, Holm Niels, Curzen N, et al. Simplex or complex stenting for bifurcation coronary lesions. A patient-level pooled-analysis of the Nordic bifurcation study and the British bifurcation coronary study. Circ Cardiovasc Interv. 2011;4:57-64.