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A 60 year old man presented for elective treatment of a bifurcation lesion, involving both the mid left anterior descending artery (LAD) and the ostium of a large diagonal branch (D1) (panel B). Intravascular ultrasound examination confirmed the narrowing of D1, suggesting that stenting the LAD alone would result in significant side branch impairment (panels A and C).
Using an 8 French guide catheter, after preinflation, two paclitaxel drug eluting stents (Taxus, Boston Scientific) were advanced to the LAD and D1. The D1 stent was then inflated while the LAD stent was left in position. Then, after removing the D1 balloon and guidewire, the LAD stent was deployed, “crushing” the proximal part of the D1 stent behind it.
After rewiring D1, a “kissing balloon” postdilatation was undertaken.
The final IVUS run confirmed an excellent angiographic appearance (panel E), with the D1 ostium wide open (panel D), and visualised the “crushed” proximal portion of the D1 stent (three layers of stent struts in the LAD proximal to the bifurcation) (panel F).
The procedure was quick and uneventful, with no enzyme rise, and the patient was discharged home the next day. Clopidogrel treatment was recommended for at least six months.
Dealing with bifurcations remains one of the challenges for interventional cardiology. In the past, randomised comparisons between strategies involving stenting only the main branch (with provisional stenting of the side branch) and various approaches using two stents, have consistently shown the inferiority of the latter, due to very high rates of restenosis, in spite of better acute angiographic results. In the era of drug eluting stents, however, encouraging preliminary data have been reported for the “crush” technique, involving sequential inflation of two stents.
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