Abstract
T and small protrusion (TAP) is a stenting technique that is utilized for the management of coronary bifurcation lesions when using a two-stent strategy. This technique is also useful whenever stenting of a main vessel (MV) jeopardizes a side branch (SB) or when a sub-optimal result is encountered in a daughter vessel after starting with one-stent approach. The conversion from one-stent strategy to TAP could be achieved smoothly and often leads to good results. Technically, optimal positioning of the SB stent to achieve the required protrusion into the lumen of the MV remains a challenge. Toward that goal we propose an added step that involves inflating a balloon in the MV to serve as an anvil with simultaneous pullback of the SB stent, to be followed by stent deployment. We refer to this approach as the snuggle T and protrusion (S-TAP) technique owing to close contact between the SB stent and the MV balloon during simultaneous inflation. In this manuscript, we detail this interventional technique and provide a demonstrative case study.
Highlights
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T and small protrusion (TAP) is a stenting technique that is utilized for the management of coronary bifurcation lesions when using a two-stent strategy.
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Optimal positioning of the side branch (SB) stent to achieve the required protrusion into the lumen of the main vessel (MV) remains a challenge.
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We detail an additional step to the TAP technique aiming an optimal positioning of the SB stent.
1
Introduction
Coronary bifurcation stenting remains challenging despite the many technical advances in interventional cardiology over the past decade. The best approach among the various strategies to deal with bifurcation lesions remains to be determined. We describe herein a case of a high grade bifurcation stenosis that was successfully treated using a modification of the two-stent technique. This modification involves adding a step to the procedure that aims at optimizing stent deployment and hopefully improving the angiographic result.
2
Case report
A 69-year old male with a history of coronary artery disease and stenting to the left circumflex (LCx) artery was admitted to our institution for elective percutaneous coronary intervention (PCI) of the mid left anterior descending (LAD) artery. A coronary angiogram was performed through the right radial access using a 6-Fr sheath. The right coronary artery was diffusely atheromatous and ectatic with no significant stenosis. For the left coronary system, a 6-Fr extra-backup (XB) 3.5 guiding catheter (Cordis, Miami, Florida, USA) was used. The LCx artery stents were patent. The LAD artery was atheromatous with severe stenosis in the mid segment at its bifurcation with the second diagonal (D2) branch ( Fig. 1 A ). The latter was a sizeable vessel with a take-off angulation of 50° to the LAD ( Fig. 1 B) and showing a severe and long stenosis involving the ostium and extending into its proximal segment. Initially, two 0.014-in. BMW guidewires (Abbott Vascular, Santa Clara, CA, USA) were advanced into the distal LAD and D2, respectively. A 2.5 mm × 20 mm Trek balloon (Abbott Vascular, Santa Clara, CA, USA) was consecutively used to pre-dilate the D2 lesion at 9 Atm ( Fig. 1 C) followed by pre-dilatation of the LAD lesion at 10 Atm ( Fig. 1 D). A 3.0 mm × 30 mm Resolute Integrity stent (Medtronic, Inc., Santa Rosa, CA, USA) was then deployed at 10 Atm in the mid LAD covering the bifurcation with D2 and jailing its guidewire ( Fig. 1 E-G). Thereafter, a third 0.014-in. BMW guidewire was advanced through the proximal part of the LAD stent and negotiated to cross the struts of the stents into D2 adjacent to the jailed guidewire and the latter was withdrawn. Consecutive inflations at the ostium of D2 using a 1.5 mm × 15 mm Mini Trek balloon at 10 Atm ( Fig. 1 H) and later a 2.0 mm × 15 mm balloon at 10 Atm ( Fig. 1 I) were performed to open the struts of the LAD stent toward the ostium of D2. Thereafter, a 2.5 mm × 22 mm Resolute Integrity stent was advanced into the proximal segment of D2 and kept uninflated. Simultaneously, a 3.0 mm × 20 mm Trek balloon was parked in the LAD, having both markers within the freshly deployed LAD stent and covering the bifurcation with D2 ( Fig. 1 J). The LAD balloon was first inflated at low pressure (6 Atm) and simultaneously the non-deployed stent parked in D2 was pulled back until its proximal tip was blocked by the inflated balloon in the LAD and then deployed at 9 Atm ( Fig. 1 K). During this maneuver, the guiding catheter was deeply engaged in the left main coronary artery (LMCA) toward the LAD as a consequence of the pullback of the D2 stent while the LAD balloon was still inflated (anchoring principle). Both balloons in the LAD and D2 were then simultaneously deflated. The D2 balloon was slightly pulled back and served along with the LAD balloon for a final kissing balloon (FKB) approach ( Fig. 1 L). The angiographic result was optimal with no residual stenosis or dissection at the bifurcation and a TIMI-3 flow throughout the LAD and D2 ( Fig. 1 M-O). The patient was discharged on medical treatment and remained asymptomatic at 2 years of follow-up.
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