Abstract
We present a case of a left anterior descending artery/diagonal branch bifurcation successfully treated with a dedicated 2-stent technique utilizing bioresorbable vascular scaffolds, where the bifurcation angle did not strictly allow a T-stenting approach. We also propose a strategy to avoid or reduce scaffold overlap in the main branch, especially important in view of the bulkier size of these novel devices.
1
Introduction
Bioresorbable vascular scaffolds (BVS) are an exciting novel treatment for coronary artery disease (CAD) as their eventual resorption renders the artery free from a permanent metallic cage. Studies to date have been promising with regards to their clinical efficacy and safety . However their use in this context has been largely limited to simple lesions. Over the last two years and since the CE Mark approval of ABSORB (Abbott Vascular, Santa Clara, CA, USA), an increasing number of ‘real-world’ patients has been treated with these devices including those with heavily calcified lesions, long diffuse disease and lesions at bifurcations sites. With this increasing experience however concerns have also been raised with regards to the use of BVS in dedicated 2-stent techniques. This has been especially the case for the culotte and ‘mini-crush’ techniques as in the case of culotte 300 μm of scaffold (strut thickness 150 μm) covers the lumen of the vessel proximal to the bifurcation site and in the case of ‘mini-crush’ approximately 450 μm on one side, albeit for a short distance. Although an approach that utilizes BVS in the main-branch (MB) and a metallic drug-eluting stent in the side branch can reduce total strut thickness, as conventional DES are much thinner, it would be ideal if the whole lesion could be treated with BVS given the theoretical advantages of these devices.
2
Case report
Here we describe a case of left anterior descending artery (LAD)/diagonal branch (Dg) bifurcation lesion (Medina classification: 1, 1, 1) where the bifurcation angle did not strictly allow a T-stenting approach and propose a strategy results to avoid or reduce scaffold overlap in the MB as much as possible. In the case presented ( Fig. 1 ), predilatation was performed in the MB and side branch (SB) with 3.5 mm and 2.5 mm non-compliant (NC) balloons, respectively. Following this a 2.5/28 mm BVS was positioned in the SB. To help with accurate placement, a balloon was advanced in the MB as indicated by Fig. 1 (on maximum magnification), to help overcome the limitations of angiography and more specifically foreshortening. Following implantation of the SB scaffold, the scaffold balloon was re-inflated at the same time as a NC balloon (3.5 mm) in the MB (kissing balloon inflation) to ensure that enough space is available for the MB scaffold to be delivered. The side balloon was the last to be deflated. We then proceeded with implantation of the MB BVS (3.5/28 mm) over the ostium of the SB, and as this did not cause SB flow deterioration, we did not postdilate the MB cells towards the SB. The final OCT images from the LAD demonstrate complete coverage of the ostium with no evidence of double scaffold layers in the MB and an adequate MB scaffold area (8.93 mm 2 ) ( Fig. 2 ).
