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A man with diabetes mellitus and left ventricular dysfunction presented with unstable angina. Before catheterization, he was treated with clopidogrel, and during the procedure he was given unfractionated heparin with adjunctive abciximab therapy. A lesion was identified in the left main coronary artery (LMCA). Rotational atherectomy was performed on both branches of the LMCA bifurcation to debulk the lesion. After predilation, bifurcation stenting with 2 drug-eluting stents (DESs) was performed with use of a crush technique. The stents were post-dilated with simultaneous kissing-balloon angioplasty at high atmospheric pressures with noncompliant (polyethylene terapthelate) balloons. Immediately thereafter, coronary angiography (Fig. 1) and intravascular ultrasound (Fig. 2) showed diffuse thrombosis that appeared to originate at the bifurcation. Serial high-pressure balloon inflations, restenting of the left main shaft into the left anterior descending coronary artery (LAD), and post-dilation with simultaneous kissing balloons were performed, with an excellent result.
Intraprocedural stent thrombosis, a potential complication of percutaneous coronary intervention, is associated with a very poor clinical outcome and high morbidity and mortality rates. Numerous risk factors for intraprocedural stent thrombosis have been identified, including lesion anatomy and severity, procedural complications, stent characteristics, and lack of response to antiplatelet therapy.1,2
There is evidence that the crush technique may increase the risk of intraprocedural stent thrombosis when it is used to treat the LMCA bifurcation. When DESs are used at the bifurcation, the observed risk of intraprocedural stent thrombosis is 0.5% to 1.3%, which reults in a high rate of in-hospital major adverse events.3,4
Although data are few, our experience has shown that rates of target-lesion revascularization appear to be lower when a single DES is used at the bifurcation. If the anatomy is suitable, we favor crossover stenting from the distal bifurcation into the LAD with predilation of the left circumflex coronary artery. After stenting, simultaneous kissing-balloon inflation in the stent and in the side-branch vessel is recommended. We consider adjunctive hemodynamic support with the use of an intra-aortic balloon pump or IMPELLA® device (ABIOMED, Inc.; Danvers, Mass) in the presence of left ventricular dysfunction, a totally occluded large right coronary artery, or the need for pretreatment of heavily calcified arteries with rotational atherectomy before DES deployment.5
Address for reprints: Matthew J. Price, MD, Division of Interventional Cardiology, Scripps Clinic, 10666 N. Torrey Pines Rd., S1056, La Jolla, CA 92037
Dr. Price has received honoraria from Abbott Vascular and Boston Scientific Corporation, and serves as a consultant for Volcano Corporation.