Case 25: PCI Manual: Reverse Crush

We describe the reverse crush (also known as internal crush) technique for treating the side branch of a coronary bifurcation if main vessel stenting compromises the origin of the side branch (which can be assessd by FFR or iFR). The side branch is rewired through the main vessel stent and predilated. A balloon is placed in the main vessel across the origin of the side branch. A stent is placed into the side branch protruding at least 2-3 mm into the main vessel and deployed. The stent balloon is removed and the main vessel balloon is inflated crushing the side branch stent struts protruding into the main vessel. The side branch is rewired through a proximal strut and final kissing balloon inflation is performed.

[@matheuscsmed]

Thank you, Matheus Silva

[@abh8404]

In our Lab here in West China, we would not put a stent in such side branch, we usually perform kissing balloon and leave it. We followed up those patients and found good long term results. I personally believe that too much metal in the proximal or mid LAD may compromise the long term results of LAD stent, thus I would rather loose a small branch instead of compromising the whole LAD...

[@dr.keroloswagdy3514]

Thanks a lot, Dr. Manos, Why did you prefer Reversed Crush as a bailout technique not TAP?
Any tips to advance the FFR stiff wire to SB?

[@nctbkh3718]

Thank you for sharing, Dr. Brilakis.
Do you use POT after kissing baloon or you think it is unnecessary. Second question is do you use jailed baloon technique to prevent plaque shifting when your plan is provisional approach? Thank you.

[@manosbrilakis]

1. I usually do POT after kissing balloon, although you are right that the kissing balloon instead may suffice given the larger combined balloon diameter proximal to the bifurcation. 2. I do not have experience with the jailed balloon technique. Thank you, Manos

[@nctbkh3718]

Thank you for replying me.

[@dranishpg]

Sir,
What are the long term results of minicrush and reverse crush on long term follow up? Any studies available? Any difference in restenosis rates between the two? And the rate of stent thrombosis? Obviously an additional layer of metal hump inside an otherwise smooth stent seems to affect the flow hemodynamics inside the vessel.
Thank you

[@revolution425]

I had the same concern. I have hard time justifying risking my LAD with so many layers of metal to save that diag.

[@schiefix]

Nowadays most people in Europe I think would do a TAP, not a reverse crush.