Abstract
We report on two cases in which Y-shaped coronary bifurcations were treated with the use of Bioresorbable scaffolds. The first case was of a 50-year-old man with NSTEMI. Coronary angiography showed stenosis involving a Y-shaped bifurcation of proximal to mid LAD and diagonal. The lesion was wired using two 0.14 BMW guide wires, followed by serial pre-dilatation of LAD and Diagonal branch. The stent into proximal LAD was deployed first as a skirt (3.5 × 12 BVS). Stent was post-dilated. A second 2.5 × 28 BVS was deployed into diagonal branch, protruding backwards; along with a 2.0 × 15 SC balloon continuing into the mid LAD. Both balloons where pulled back proximally and re-inflated. The technique was repeated in reversed order for stenting the mid LAD using the third BVS (3.0 × 18 BVS). Finally two NC balloons where used to post-dilate both legs of the newly-formed trouser. The result was checked by OCT. The second case was that of a 62-year-old man with chest pain and NSTEMI. He had a history of previous PCI to LCx using bare metal stent. Coronary angiogram showed severe in-stent restenosis in mid LCX, extending into two large obtuse marginal branches. After wiring both OMs, serial pre-dilatation was done with two NC 2.5 × 20 balloons, followed by initial stenting of mid LCx inside old stent, as the proximal segment of bifurcation, using a 3.5 × 12 BVS, followed by implanting a 2.5 × 28 BVS into OM2 and 2.5 × 18 into OM1. At 6 months a clinical follow up via telephone contact revealed no recurrence of chest pain in both cases and no further intervention required.
Highlights
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Established fact 1: Bioresorbable scaffolds are heralded as the next revolution in interventional cardiology.
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Established fact 2: There is a tendency to avoid utilizing BVS in treating true coronary bifurcations when the side branch occlusion may lead to clinically dismal consequences.
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Novel insight 1: In selected cases, the use of BVS in the order of “skirt followed by trouser” preserves the native anatomy of Y-shaped coronary bifurcation without jeopardizing flow or access to side branch while avoiding the hazards of BVS strut breakage.
We report on two cases in which Y-shaped coronary bifurcations were treated with the use of Bioresorbable scaffolds (Abbott Vascular, Santa Clara, CA, USA). The first case was of a 50-year-old man, smoker for twenty years with no past chronic illnesses. He presented to emergency department with persistent chest pain. ECG showed T wave inversion in leads I, aVL, V4–V6. Cardiac enzymes where elevated. He was shifted for early coronary intervention, which showed coronary single vessel disease. There was haziness involving a Y-shaped bifurcation of proximal to mid LAD with large diagonal branch ( Fig. 1 .). In view of patient’s young age decision was taken to treat it using BVS. The lesion was wired using two 0.14 HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL Guide Wires (Abbott Vascular). This was followed by serial pre-dilatation of LAD and Diagonal branch at 1:1 ratio ( Fig. 2 a–c). The stent into proximal LAD was deployed first as a skirt (3.5 × 12 BVS; Abbott Vascular, Santa Clara, CA, USA) ( Fig. 3 a), then the wires were withdrawn and re-inserted through the stent lumen into mid LAD and Diagonal. This stent was post-dilated using a short NC Balloon. Next a second 2.5 × 28 BVS (Abbott Vascular, Santa Clara, CA, USA) was deployed into diagonal branch and minimally protruding backwards into the proximal LAD stent. It was deployed along with a 2.0 × 15 SC balloon placed minimally into skirt stent and continuing into the mid LAD as a modified v stenting technique ( Fig. 3 b). After stent deployment both balloons where pulled back proximally and re-inflated at higher pressures inside the skirt BVS. The technique was repeated in reversed order for stenting the mid LAD using the third BVS (3.0 × 18 BVS; Abbott Vascular, Santa Clara , CA, USA) and a 2.0 × 15 balloon in the diagonal side branch ( Fig. 3 c). Finally two NC balloons where used to post-dilate both legs of the newly-formed trouser ( Fig. 3 d). The result was checked by OCT ( Fig. 4 a–b), which showed good strut opposition to vessel walls and no strut breakage. There was no area left un-stented inside the bifurcation lesion.
