Abstract
Percutaneous coronary interventions involving coronary bifurcation lesions are more complex and associated with adverse outcomes (both angiographic and clinical) compared to non-bifurcation lesions. Tryton, a dedicated bifurcation stent, has been introduced with the aim to simplify treatment of bifurcation lesions. Tryton stent in combination with conventional drug eluting stent is safe and associated with reduced stenosis and bail-out stenting of side branch compared to provisional stenting involving a large side. However, little is known regarding safety and efficacy of Tryton stent in left main (LM) bifurcation lesion. We describe two cases of unprotected LM bifurcation stenting using Tryton stent in combination with drug eluting stent.
Highlights
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Two-stent technique is preferred to achieve better angiographic results in true distal left main (LM) bifurcation disease.
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Two-stent technique is more complex with higher risk of procedure related complications.
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Tryton bifurcation stents have recently been introduced with the aim to simplify treatment of bifurcation lesions.
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Treatment of LM bifurcation disease with Tryton stent in combination with drug eluting stents is feasible and safe.
1
Introduction
Coronary bifurcation lesions are encountered in approximately 15–20% of all percutaneous coronary interventions (PCI) performed [ , ]. PCIs involving coronary bifurcation lesions are more complex and associated with adverse outcomes (both angiographic and clinical) compared with non-bifurcation lesions [ ]. Dedicated bifurcation stents have recently been introduced with the aim to simplify treatment and improve early and late outcomes following stenting of bifurcation lesions. Tryton bifurcation stent (Tryton Medical, Inc., Durham, NC, USA) in combination with conventional drug eluting stent has been shown to be safe and is associated with reduced stenosis and bail-out stenting of side branch (SB) compared to provisional stenting involving a large SB (>2.25 mm by quantiave coronary angiography) [ ]. However, little is known regarding safety and efficacy of Tryton stent in left main (LM) bifurcation lesions. We describe two cases of unprotected LM bifurcation stenting using Tryton stent in combination with drug eluting stent.
2
Case description
2.1
Case 1
A 66 year old male with prior history of type A aortic dissection status post aortic root replacement with aortic valve repair presented with acute heart failure. Echocardiography revealed severe left ventricular systolic dysfunction with an ejection fraction of 15% and moderate mitral regurgitation. After optimization of his volume status, he underwent cardiac catheterization, which showed distal LM bifurcation disease with 80% ostial left anterior descending (LAD) artery and 70% ostial left circumflex (LCX) artery stenoses (medina 0,1,1), a mid LAD 70% stenosis and a small nondominant right coronary artery (RCA) ( Fig. 1 a–b, Video 1 ). He was evaluated by a heart team and deemed to be a poor candidate for coronary artery bypass graft surgery given his severely impaired LV systolic function and redo-surgery. The mid LAD lesion was treated first with two 3.0 × 15 Xience Alpine stents (Abbott Vascular, Santa Clara, CA). The LM bifurcation lesion was then treated using a Tryton 3.5 × 4.0 × 15 mm-6Fr stent and a 4.0 × 18 mm Xience Alpine stent ( Fig. 2 , Video 2 ). IMPELLA CP (Abiomed, Danvers, MA) through right femoral artery was used for hemodynamic support during PCI. Intravascular ultrasound (IVUS) was used for optimization of PCI. He was discharged home the next day and has been doing well at 10-month follow up.
2.2
Case 2
A 67 year old male presented to the hospital with Non ST-elevation myocardial infarction and acute exacerbation of heart failure with reduced ejection fraction. He had initially presented one month ago with acute congestive heart failure and was found to have new onset severe left ventricular systolic dysfunction with ejection fraction of 30%. Diagnostic coronary angiogram showed distal LM 75% stenosis involving ostial LAD and LCX (medina 1,1,1) along with a mid LCX 70% and mid RCA 80% stenoses ( Fig. 3 , Video 3 ). The revascularization of coronary artery was put on hold due to ongoing induction chemotherapy for chronic lymphocytic leukemia. Meanwhile, he was being treated with guideline-directed medical therapy, but continued to have recurrent hospitalizations for acute on chronic congestive heart failure. He was deemed to be a poor candidate for surgical revascularization by heart team evaluation. He underwent PCI of mid RCA with 3.0 × 23 and distal RCA with 2.5 × 18 Xience Alpine stents. One week later, he was brought back for PCI of mid LCX and distal LM. Impella 2.5 through left femoral artery was used for hemodynamic support during PCI. The mid LCX was treated first with 3.0 × 33 Xience Alpine stent. LM bifurcation lesion was treated with 3.0 × 3.5 × 15 mm-6FR Tryton stent and 3.5 × 38 mm Xience Alpine stent with IVUS guidance ( Fig. 4 , Video 4 ). He was discharged home the next day and was noted to be doing well at 6-month follow up.
2
Case description
2.1
Case 1
A 66 year old male with prior history of type A aortic dissection status post aortic root replacement with aortic valve repair presented with acute heart failure. Echocardiography revealed severe left ventricular systolic dysfunction with an ejection fraction of 15% and moderate mitral regurgitation. After optimization of his volume status, he underwent cardiac catheterization, which showed distal LM bifurcation disease with 80% ostial left anterior descending (LAD) artery and 70% ostial left circumflex (LCX) artery stenoses (medina 0,1,1), a mid LAD 70% stenosis and a small nondominant right coronary artery (RCA) ( Fig. 1 a–b, Video 1 ). He was evaluated by a heart team and deemed to be a poor candidate for coronary artery bypass graft surgery given his severely impaired LV systolic function and redo-surgery. The mid LAD lesion was treated first with two 3.0 × 15 Xience Alpine stents (Abbott Vascular, Santa Clara, CA). The LM bifurcation lesion was then treated using a Tryton 3.5 × 4.0 × 15 mm-6Fr stent and a 4.0 × 18 mm Xience Alpine stent ( Fig. 2 , Video 2 ). IMPELLA CP (Abiomed, Danvers, MA) through right femoral artery was used for hemodynamic support during PCI. Intravascular ultrasound (IVUS) was used for optimization of PCI. He was discharged home the next day and has been doing well at 10-month follow up.
2.2
Case 2
A 67 year old male presented to the hospital with Non ST-elevation myocardial infarction and acute exacerbation of heart failure with reduced ejection fraction. He had initially presented one month ago with acute congestive heart failure and was found to have new onset severe left ventricular systolic dysfunction with ejection fraction of 30%. Diagnostic coronary angiogram showed distal LM 75% stenosis involving ostial LAD and LCX (medina 1,1,1) along with a mid LCX 70% and mid RCA 80% stenoses ( Fig. 3 , Video 3 ). The revascularization of coronary artery was put on hold due to ongoing induction chemotherapy for chronic lymphocytic leukemia. Meanwhile, he was being treated with guideline-directed medical therapy, but continued to have recurrent hospitalizations for acute on chronic congestive heart failure. He was deemed to be a poor candidate for surgical revascularization by heart team evaluation. He underwent PCI of mid RCA with 3.0 × 23 and distal RCA with 2.5 × 18 Xience Alpine stents. One week later, he was brought back for PCI of mid LCX and distal LM. Impella 2.5 through left femoral artery was used for hemodynamic support during PCI. The mid LCX was treated first with 3.0 × 33 Xience Alpine stent. LM bifurcation lesion was treated with 3.0 × 3.5 × 15 mm-6FR Tryton stent and 3.5 × 38 mm Xience Alpine stent with IVUS guidance ( Fig. 4 , Video 4 ). He was discharged home the next day and was noted to be doing well at 6-month follow up.
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