Introduction
Coronary bifurcation stenting remains a formidable challenge in interventional cardiology due to its complexity and the inherent risk of stent thrombosis and restenosis, even with contemporary techniques. Additionally, calcified coronary lesions pose a significant hurdle for interventional cardiologists, as they not only increase the risk of immediate complications during percutaneous coronary interventions (PCI) but also elevate the potential for late stent failure due to under-expansion and/or malposition. As such, these challenging lesions have a substantial prognostic impact on patients’ outcomes. Accurate identification of calcified plaques, along with an in-depth analysis of their distribution within the vessel wall using intracoronary imaging, plays a crucial role in improving the successful treatment of these lesions. This article highlights a particular case from Al Zahra Hospital Dubai, illustrating how the utilization of a stent-enhanced visualization technique, CLEAR Stent, played a crucial role in averting major complications and facilitating a secure procedure that ultimately yielded an optimal outcome.
Clinical Case Presentation
We present the case of a 58-year-old man with a history of diabetes, hypertension, and dyslipidemia who presented with unstable angina. Coronary angiography revealed severe triple vessel disease, and a collaborative decision was made by the heart team, the patient, and his family to proceed with high-risk PCI.
LAD: Major diagonal are heavily calcified and significantly diseased.
LCX: Calcified vessel with long significant lesion at distal part
RCA: Chronic total occlusion and filled via left system.
Left coronary artery (LCA) angiogram showed a highly calcified LAD-diagonal bifurcation lesion, which IVUS indicated required atherectomy.
Atherectomy was expertly performed using the OA (diamond black) system, yielding an angiogram that displayed an optimal luminal gain. The procedural strategy of choice included pre-dilatation with a non-compliant (NC) balloon and the deployment of the Double Kiss Crush technique. This comprehensive approach encompassed the stenting of the diagonal branch, sequential steps involving stent deployment, crush, recrossing, and the crucial first-kiss step. Subsequently, the LAD, as the major branch, was stented, followed by post-dilatation (POT) and a second recrossing, concluding with the final kissing maneuver. Enhanced stent visualization played a pivotal role throughout various stages of the procedure, aiding in precise stent placement, optimizing the proximal region, and ensuring the successful positioning of the main vessel stent, as depicted in the accompanying images.
Following the stent placement in both the LAD and diagonal branch, the coronary angiogram revealed an acceptable outcome, demonstrating a TIMI flow grade of III. At this juncture, IVUS imaging demonstrated well-apposed stents. However, adhering to a standard practice in complex interventions, it is highly advisable to incorporate stent-enhanced visualization before concluding the procedure. This step is critical in ensuring the absence of residual stenosis, stent fractures, plaque protrusions, and under-expansion. Notably, in our case, a surprising observation emerged, revealing that the distal portion of the main vessel stent was not fully expanded. Left untreated, this issue poses a significantly heightened risk of stent thrombosis, which could lead to catastrophic consequences, including myocardial infarction, mortality, and heart failure.
In this instance, despite thorough lesion preparation through pre-dilatation and atherectomy, the post-dilatation with a noncompliant (NC) balloon proved ineffective. Consequently, a high-pressure OPN balloon, inflated up to an impressive 34 ATM, was employed to achieve the necessary stent expansion. The utilization of CLEAR Stent visualization verified the attainment of the optimal result.
The final angiogram and IVUS evaluation demonstratedthe optimal outcome of the PCI procedure. The stent was exceptionally well expanded and fully apposed, with no residual stenosis or evidence of edge dissection. After the successful intervention, the patient was safely discharged the next day.
Contact
Al Zahra Hospital, Dubai, UAE
Head of Cardiology
Al Zahra Hospital, Dubai, UAE