SS–03 Percutaneous Coronary Intervention with the DK-Crush Technique for a Complex LAD–Diagonal Bifurcation Lesion in the Setting of Acute Anterior Myocardial Infarction

Abstract

Introduction and Aim: : Coronary bifurcation lesions account for approximately 15–20% of all percutaneous coronary interventions (PCI). True bifurcation lesions of the left anterior descending artery (LAD) and a large diagonal branch are among the most technically demanding PCI scenarios in acute ST-elevation myocardial infarction (STEMI). Double kissing (DK) crush has been associated with superior outcomes compared with other two-stent techniques in complex bifurcation lesions; however, repeated wire crossings and kissing balloon steps may create technical difficulties in the time-constrained acute setting. We present an LAD–second diagonal (D2) true bifurcation lesion treated with DK-crush during primary PCI, complicated by three distinct technical challenges.

Case Report: A 66-year-old man with no known cardiac history presented with chest pain and ST elevation in the anterior leads on electrocardiography. Blood pressure was 141/93 mmHg, heart rate 78 bpm, oxygen saturation 97%. Echocardiography showed an ejection fraction of 40% with anterior wall and apical hypokinesia. Emergency angiography via a right femoral 7F sheath revealed a markedly elongated aorta and a superiorly originating left main coronary artery; a true bifurcation lesion with 90% calcific stenosis in the LAD proximal to the D2 origin and 90% stenosis in the proximal D2 was identified, and DK-crush was planned. Both branches were wired separately through an EBU 4.5 guiding catheter. During predilatation, refractory loss of flow developed in D2; as repeated prolonged balloon dilatations failed, 10 mg of intracoronary tissue plasminogen activator was administered within 10 minutes, and flow was restored after prolonged inflation with a 2.75×30 mm non-compliant (NC) balloon. A 2.75×22 mm drug-eluting stent was implanted in D2, followed by proximal optimization technique (POT) and the first kissing balloon. After the first crush, a 3.0×32 mm stent could not be advanced into the LAD; after exchange for a more supportive wire with microcatheter support and re-crushing of the side branch stent with a 4.0×8 mm NC balloon, the second kissing balloon was performed and the stent implanted successfully. Repeat POT and kissing balloon provided complete angiographic patency of the bifurcation. At the end of the procedure, 99% ostial stenosis (jailing) developed in a well-developed first diagonal branch (D1) arising proximal to the stent; this branch was rewired and opened with 2.0×10 mm balloon angioplasty without stent deformation. TIMI 3 flow was obtained in the LAD, D1 and D2. He was monitored in the coronary intensive care unit under inotropic support; apart from a self-terminating 10–15-second episode of non-sustained ventricular tachycardia, no complications occurred. He was discharged on acetylsalicylic acid, prasugrel, rosuvastatin, ramipril and metoprolol, with outpatient follow-up at 1 month.

Conclusion: LAD–diagonal true bifurcation lesions can be treated successfully with DK-crush in acute STEMI; however, difficult stent delivery in calcified and tortuous anatomy, refractory side branch no-reflow and jailing of an adjacent side branch should be anticipated. This case suggests that low-dose intracoronary thrombolysis added to prolonged balloon dilatation in refractory no-reflow, and wire exchange with a repeat crush maneuver when the stent cannot be advanced after the first crush, may be effective bailout strategies.