The combination of drug-eluting stents and the crush technique with final kissing balloon inflation for the treatment of coronary bifurcation lesions is associated with superior clinical and angiographic outcomes.1,2 However, the crush technique involves simultaneous manipulation of 2 bulky stents inside a vessel and has a limited success rate of final kissing balloon inflation.1–3 In more complex lesion subsets, the crush technique may not be technically feasible. Recently, Jim et al described the “sleeve technique”, which reconstructs the side branch (SB) and the main vessel (MV) in a stepwise fashion.4 A perfect rate of final kissing balloon inflation was reported in a small preliminary study.4 The author has applied the sleeve technique to treat a left anterior descending artery (LAD) long, diffuse lesion that contained 2 sizable and diseased diagonal branches (double-bifurcation lesion). Case Report. A 71-year-old female presented with acute coronary syndrome with electrocardiography showing diffuse ST-segment depression in leads V2–6. Her creatinine kinase and troponin levels were not elevated. Her cardiovascular risk factors included diabetes mellitus, hypertension and hypercholesterolemia. Coronary angiography revealed separated LAD and left circumflex artery (LCX) origins. The LAD was small in size with a very long and critical disease from its proximal to distal course, and there were 2 sizable diagonal branches coming out from the mid LAD (double-bifurcation lesion) (Figures 4 and 5). The first diagonal branch (D1) was diseased, while the second diagonal branch (D2) ostium was 50% narrowed. The LCX was also a small-sized vessel. The first obtuse marginal branch and the distal LCX were totally blocked (Figure 6). The right coronary artery (RCA) was comparatively large and dominant. There were critical lesions in the proximal and distal RCA, as well as the posterior descending artery (PDA) and posterolateral branches (PLB) (Figure 7). Left ventriculography showed mildly impaired left ventricular function with apical hypokinesia. The angiogram was presented to the cardiothoracic surgeon for consideration of coronary artery bypass graft surgery. In view of the patient’s small vessel size and disease involvement of the distal vessels, bypass surgery was considered unsuitable and offering doubtful benefit. The patient was also very reluctant to undergo open-heart surgery. After careful and detailed explanation of the pros and cons and the benefits and risks of percutaneous coronary intervention (PCI), staged PCI procedures were decided upon. The RCA was tackled first with the intent to improve perfusion of the inferolateral wall prior to the predicted long, tedious LAD bifurcation reconstruction procedure, and thereby improving the patient’s ischemic tolerance. In addition, the RCA was very dominant and larger in size, and thus functionally more important relative to the LAD. Preprocedure intravenous fluid hydration was started 1 day prior to the procedure. Several Taxus® paclitaxel-eluting stents (Boston Scientific Corp., Natick, Massachusetts) were implanted in the RCA (4.0 x 32 mm), the PDA (2.5 x 16 mm) and the PLB (2.5 x 16 mm). A staged reconstruction of the LAD and 2 of its diagonal branches was performed approximately 4 weeks later. The patient was already on aspirin 150 mg daily for several months and clopidogrel 75 mg daily since the last PCI procedure. During PCI, an intra-arterial bolus of 5,000 units of unfractionated heparin was administered. In addition, an intravenous bolus, followed by infusion of abciximab, was given according to the recommended dosage. The activated clotting time was 340 seconds. A 7 Fr XB 3.5 guide catheter (Cordis Corp., Miami, Florida) was used to select the LAD. Roadmap angiograms revealed a long, diffuse 80–95% lesion extending from the proximal to distal LAD, with 2 sizable diagonal branches in close proximity to one another (Figures 4 and 5). Using the guide catheter as the reference, the size of the LAD and diagonal branches were visually estimated to measure about 2.5 mm and 2.0 mm, respectively. The LAD and its 2 diagonal branches were wired with a BMW Universal 0.014 inch x 190 cm wire (Guidant Corp., Indianapolis, Indiana) and PT2 (light support) 0.014 inch x 185 cm wires (Boston Scientific), respectively. The entire LAD was predilated with a Tempo™ Aqua 2.0 x 15 mm catheter (Cordis) at 10–14 atmospheres (atm). The mid-distal LAD segment, which had no SB, was stented with a Cypher™ 2.25 x 33 mm stent (Cordis), deployed at 14 atm. A Cypher 2.25 x 13 mm stent was then advanced into the D2, leaving 3 mm of the proximal segment of the stent protruding into the LAD. At the same time, a Sprinter 2.5 x 15 mm balloon (Medtronic, Inc., Minneapolis, Minnesota) (LAD balloon) was positioned in the LAD to cover the protruding stent segment (standby position). The stent was deployed at 14 atm. The stent balloon was removed. Angiography showed no distal stent dissection. The D2 wire was removed and the LAD balloon was inflated at 16 atm to crush the protruding stent segment against the LAD wall. Another Cypher 2.25 x 13 mm stent was then advanced into the D1, leaving 3 mm of the proximal segment of the stent protruding into the LAD. While the LAD balloon was in the standby position, deployment of the D1 stent was performed at 14 atm. The wire and the stent balloon were removed. The protruding segment of the D1 stent was crushed with the LAD balloon as described previously. The PT2 wire was used to rewire the D2 through its own stent strut. A Sprinter 2.0 x 6 mm balloon (SB balloon) (Medtronic) was advanced across the D2 ostium. While the LAD balloon was in standby position, the SB balloon was inflated at 18 atm. Kissing balloon inflation was performed in the LAD/D2 bifurcation at 14 atm. The PT2 wire was then used to rewire the D1 through its own stent strut. The SB balloon was advanced across the D1 ostium. While the LAD balloon was in standby position, the SB balloon was inflated at 18 atm. The LAD/D1 bifurcation was then kissed with the balloons at 14 atm. By this time, the D1 and D2 ostia were reconstructed like 2 new sleeves. The proximal LAD was stented with a Cypher 2.5 x 33 mm stent at 14 atm, overlapping the previously-deployed LAD stent. The PT2 wire was used to rewire the D2 through the LAD stent strut. The SB balloon was advanced across the D2 ostium. While the LAD balloon was in standby position, the SB balloon was inflated at 18 atm. Kissing balloon inflation was performed the second time in the LAD/D2 bifurcation with the 2.5 mm and 2.0 mm balloons inflated at 14 atm. The PT2 wire was then used to rewire the D1 through the LAD stent strut. The SB balloon was advanced across the D1 ostium. While the LAD balloon was in standby position, the SB balloon was inflated at 18 atm. Kissing balloon inflation was performed the second time in the LAD/D1 bifurcation at 14 atm. Final angiography showed an excellent result, with widely patent diagonal branch ostia (Figures 8–10). The total procedure time was 125 minutes, and 220 ml of contrast was used. The baseline and postprocedure creatinine levels were 67 µmol/L and 77 µmol/L, respectively. The patient was monitored in the coronary care unit overnight. There was rise in the patient’s enzyme, and she was discharged the next day. The patient had experienced no cardiac events when she was seen in the outpatient clinic 4 weeks later. She was prescribed aspirin for life and clopidogrel 75 mg daily for 1 year. Discussion. In the field of interventional cardiology, diabetes mellitus is a poor clinical prognostic factor owing to its strong association with multivessel involvement, small-vessel caliber and complex lesion characteristics5–10 which are prone to in-stent restenosis and recurrent clinical events.11–13 The immediate result is likely to be disappointing in bifurcation lesions due to their predisposition to SB occlusion.14–15 The prognosis is even worse in double-bifurcation lesions. To date, literature concerning the proper management and treatment outcome of the latter lesion subset is lacking. Treatment of these complex lesions is thus totally anecdotal. In the present case, the double-bifurcation long lesion was located in a small-sized, diffusely diseased LAD. PCI was very unlikely to achieve an optimal result and had a high risk of periprocedural adverse events. From a technical point of view, provisional T-stenting would not guarantee SB access and would not be able to provide complete coverage of the SB ostium. The conventional crush technique was also excluded in this case, as it would involve simultaneous delivery of 3 stents and would require at least a 10 Fr guide catheter. Recently, Jim et al described the sleeve technique,4 which works by separate reconstruction of the SB and MV. It involves initial stenting of the SB ostium, balloon-crush of the proximal protruding stent segment against the MV wall, reconstruction of the SB ostium by kissing balloon inflation, and is followed by stenting of the MV and reconstruction of the MV/SB bifurcation again by second kissing balloon inflation. A 7 Fr guide catheter is sufficient for the procedure, as only 1 balloon and 1 stent at the most are present simultaneously in the guide catheter. Unlike the conventional crush technique, only 1 layer of stent strut is traversed each time during SB recrossing. Complete reconstruction of the bifurcation requires two recrossings of the SB and two kissing balloon inflations instead of one. This process may allow more complete stent expansion and apposition. Whether this could be translated into clinical benefit needs further study. The long-term outcome of this patient needs close monitoring and follow-up angiography, but a good acute angiographic result is the prerequisite for future success. This case report clearly illustrates the versatility of the sleeve technique. In conclusion, the sleeve technique is a modified version of the crush technique, and has been shown to be effective in treating coronary bifurcation lesions in a small preliminary study.4 It involves separate and stepwise reconstruction of the SB and the MV. The versatility of this technique is further proven in this report by the total reconstruction of a long diffuse LAD double-bifurcation lesion. Thus the strategy of the combination of drug-eluting stents, sleeve technique and glycoprotein IIb/IIIa inhibition use might be the best solution for the more complex coronary bifurcation lesions.
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