June 30th 2008 www.tctmd.com

    By Deepak Natarajan

    Monday, June 30, 2008


    Deepak Natarajan(MD, DM) and Vivek Prakash(DM)


    Indraprastha Apollo Hospitals,New Delhi


    Departments of Cardiology, Indraprastha Apollo Hospitals, New Delhi, India


    A 69 yr old non diabetic male who had already received one bare metal stent each in his proximal LAD and mid RCA 4 years ago was readmitted for severe typical chest pain at rest, with ischemic ECG changes and positive troponin I values. On examination his heart rate was 60/min, blood pressure 180/110 mm Hg and he had a loud first sound with clearly audible S4. There was no evidence of heart failure.


    His coronary angiogram revealed

    Left main : normal.
    LAD : Patent stent and rest of the vessel normal (Figure 1).
    Left Cx ; Patent stent with non critical proximal lesion of 30%.
    RCA ; Patent stent with 75 %to 90% stenosis involving the RCA/PDA bifurcation (Figure 2).
    LV angiogram : Normal size LV with good LVEF of 60%.


    The right coronary artery was engaged with a 7Fr JR guiding catheter and a floppy wire 0.014 was introduced across the lesion into the PDA. Following predilatation by a 2.0/15 mm balloon a 2.5/20 PES was deployed at 18 atm (Figure 3). Angiograms demonstrated no residual stenosis in the stent but a 90% ostial stenosis in the Postero-lateral branch secondary to the stent (Figure 4). A new hydrophilic wire was negotiated across the stent into the large PLV branch and the struts dilated with an 1.5/10 mm balloon. A 2.0/10 PES positioned with its proximal end 2mm within the MV for an internal crush (Figure 5). Following deployment of the SB stent at 16 atm and a repeat angio the SB stent was next crushed with a 2.5+20 balloon at 20 atm (Figure 6 and Figure 7). The side branch stent struts were expanded by a 2+10 mm balloon at 16 atm (Figure 8) and eventually kissing balloon angioplasty was employed to achieve excellent results (Figure 9).


    There was no residual stenoses or dissection (Figure 10 and Figure 11). The procedure was preceded by 2 bolus injections of eptifibatide. He was discharged after 2 uneventful days in the hospital on aspirin,clopidogrel,cilostazol and fondaparinux.


    Management of bifurcation lesions continue to evolve rapidly with the provisional stenting approach considered to be the best. As the PLV branch had no lesion this was a classic case for provisional stenting of the side branch. The internal crush should prove to be the easiest,safest and most logical approach in such lesions.

    Conflict of Interest: