Case 172: Manual of PCI - Double bifurcation
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- čas přidán 13. 06. 2024
- A patient was referred for PCI of a double bifurcation lesion: (a) LAD diagonal bifurcation and (b) bifurcation of the diagonal into a superior and an inferior branch. Coronary physiology with a pressure wire and AngioFFR was performed showing a long lesion in the LAD and a more focal lesion in the diagonal. The superior diagonal branch did not have significant stenosis, hence provisional stenting was chosen for the diagonal bifurcation. DK crush was chosen for the LAD/diagonal bifurcation. After predilatation the diagonal lesion was stented covering the ostium of the superior branch and protruding the stent into the LAD. DK crush was successfully used in the LAD/diagonal bifurcation with an excellent final angiographic result. Post PCI FFR and FFRangio in the LAD were 0.92 and 0.93, respectively. The diagonal could not be crossed with the pressure wire after LAD/diagonal stenting but FFRangio was 0.93.
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Great cases as usual Manos. My only point is about the LAD stent, you chose 2.25 mm diameter. POT with 3.5 will lead to over expansion . The ONYX 2.25 goes up 3.25. I would have used a larger diameter and deployed at lower pressures then post dilated accordingly.
I agree with your opinion about stent size and need IVUS or OCT to confirm the proximal stent is good apposition.
This looks like 2.75 stent.
Not 2.25
May be Onyx Frontier as Onyx Frontier 2.0--2.5 mm expand up to 3.5 mm
Great point!
Thanks for the excellent case presentation.
Excellent job
Caution is needed when pressure wires are advanced through MB stent to check pinched side branches, especially
in some case of high calcium burden at bifurcation (even after stenting) these pressure wires can easily get stuck leading to unpleasant complications.
I would always use FFR Angio after stenting as it was perfectly mentioned here
Could we use DCB in DG and only provisional stenting for LAD in this case ?
Do we have to see from another angle how much we protruding into lad when we implanting first stent?
nice case , I have a couple of questions if I may: First: Would it be safer to avoid ballooning the superior diagonal branch beforehand? second:2.25 is too small a stent to put in LAD, isnt it?
Good points - Agree that not predilating the SB is preferable to minimize the risk of dissection. Also agree re:stent sizing but it is usually better to start with a smaller stent and postdilate to larger diameter than start with a larger stent that may cause distal edge dissection.
Many advocates the use of OCT for bifurcation stenting, especially for making sure the proper SB strut wiring before 2nd kissing balloon..what is your view on that? Thank you
Absolutely! Intravascular imaging is extremely useful in bifurcation PCI.
Excellent case.In case of severe lesion not moderate one, do you still relay on FFR for strategy planning? Thanks
If lesion is very severe angiographically I do not use FFR as it is almost always positive - post PCI FFR can be useful even in such cases though.
Are you sure lad stent was 2.25 mm.what stent do you use that can go upto 3.5 from 2.25 mm?also,did you post dilate distal part of stent?
Yes, stent can be postdilated to 3.5 mm.
Nice result. But are you concerned for Ostial pinching of superior branch?
Yes but decided to not do additional ballooning as the patient was asymptomatic and the branch had TIMI 3 flow.
@@manosbrilakis will angio ffr can help here.?
It seems like there is some compromise on the ostium of the upper branch of diagonal. Do you think in the future it May cause problem?
Good point - this is definitely possible - it can often be challenging to strike a balance about what is "enough" or not.