transradial complex left main trifurcation intervention

Case Reports

Transradial Complex Left Main Trifurcation Intervention

Hesham Hussein,1 MD, Hsiu-Yu Fang,2 MD, and Chiung-Jen Wu,2* MD

Trifurcation lesions, especially around the left main coronary artery (LMCA), are occa-sionally encountered. Complex lesions, involving the bifurcation or the trifurcation of theunprotected LMCA, represent a real challenge for interventional cardiologists. Trifurca-tion lesions intervention reported to have high overall major adverse cardiovascularevents, and require the use of various complex interventional techniques, for example,large guiding catheters to accommodate three wires guiding simultaneously inflated bal-loons or stents. Here, we report a case of successful percutaneous coronary interventionsupported by pre-and post-intravascular ultrasound imaging, on an LMCA trifurcationusing a 6F guiding catheter via transradial approach. VC 2010 Wiley-Liss, Inc.

Key words: trifurcation; transradial cath; 6-French guiding; intravascular ultrasound;left main coronary disease; Culotte technique

INTRODUCTION

Left main coronary artery (LMCA) bifurcationlesions remains a technical challenge for interventionalcardiologists with the disadvantage of worse clinicaloutcomes and a higher rate of restenosis when com-pared with nonbifurcation lesions [1,2]. Trifurcatingcoronary disease is characterized by unique coronaryanatomical changes that challenge even the most expe-rienced operators, especially when atherosclerotic dis-ease involves concomitantly the main vessel (eitherproximally and/or distally) and the side branches (SBs;usually the ramus intermedius and left circumflex)[3,4]. The development and use of drug-eluting stentshas recently brought major benefits in terms of reduc-tion of restenosis and repeat revascularization, espe-cially in the high risk distal LMCA patients with highermajor adverse cardiac events (MACE) [5]. To date, lim-ited data have been reported on percutaneous coronaryinterventions (PCI) in unprotected left main coronaryartery (ULMCA) trifurcation disease [6]. Complex de-vice interventions including simultaneous triple-ballooninflation necessitating larger guiding catheters arerequired for complete and effective disease treatment.Here, we report a case of intravascular ultrasound(IVUS)-guided PCI of LMCA trifurcation lesion usinga 6F guiding catheter via transradial approach.

CASE REPORT

Our patient was a 59-year-old male smoker withhypertension, diabetes, dyslipidemia, and history of an-

gina for more than 2 years. He presented with a 20-day history of recurrent episodes of chest pain. Theechocardiogram showed an ejection fraction of 60%with no regional wall motion abnormality; his thaliumscan showed reversible ischemia in the left anterior de-scending artery (LAD) territory. Coronary angiographydone 3 days later revealed a diffusely diseased rightcoronary artery without critical stenosis. The left coro-nary artery showed 75% stenosis at the distal LMCA

1Department of Cardiology, National Heart Institute, Cairo,Egypt2Division of Cardiology, Department of Internal Medicine,Chang Gung Memorial Hospital-Kaohsiung Medical Center,Chang Gung University College of Medicine, Taiwan, Republicof China

This case was presented and discussed as challenging case during

the Transcatheter therapeutics 2009 (TCT 2009), San Francisco,

USA

Conflict of interest: Nothing to report.

*Correspondence to: Chiung-Jen Wu, MD, Division of Cardiology,

Department of Internal Medicine, Chang Gung Memorial Hospital—-

Kaohsiung Medical Center, Chang Gung University College of Medi-

cine, 123 Ta Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan,

R.O.C. E-mail: [email protected], [email protected] or

[email protected]

Received 9 November 2009; Revision accepted 16 November 2009

DOI 10.1002/ccd.22391

Published online 7 September 2010 in Wiley Online Library

(wileyonlinelibrary.com).

VC 2010 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 76:679–683 (2010)

with focal haziness suggestive of a recent plaque rup-ture. The LAD and left circumflex artery (LCX) werenearly equal in vessel size with 75–80% stenosis inand ostial portions, both had 75–80% stenosis interme-diate branch had a relatively small vessel caliber with50% ostial stenosis. The trifurcation lesion showed an�45� inter-vessel angle and was classified as a Medina1,1,1,1 lesion. The calculated Euroscore and Syntaxscores were 6 and 26, respectively.

As per patient preference, ad hoc LMCA PCI usingIVUS-guided two stent strategy Culotte technique wasplaned. A 6-French (6F) arterial sheath (10 cm) wasinserted, and a 6F Ikari-left 3.5 guiding catheter (Ter-umo Corporation, Tokyo, Japan) engaged the LMCAthrough the right radial artery. Two 0.014-in. Run-through guide wires (Terumo Corporation) wereadvanced into the distal LAD and the Ramus branch,another 0.014-in. Rinato wire (ASAHI INTECC, Japan)was advanced in the distal LCX. All three ostiallesions were dilated sequentially with a Maverick 2.5mm � 20 mm balloon (Boston scientific) at 12 atm.An IVUS examination revealed a diffuse fibrocalcificplaque with a minimal lumen area (MLA) of 3.0 mm2

in the LCX ostium and MLA of 5.9 mm2 at the site ofthe plaque rupture in the distal LM. An IVUS exami-nation showed negative remodeling in the mid LADand MLA of �3.12 mm2 in the ostial LAD. A TaxusLiberte 3.5 mm � 28 mm stent (Boston Scientific) wasdeployed from the mid LMCA to the proximal LCX at10 atm followed by post dilatation of the stent with aMaverick 3.5 mm � 20 mm balloon at 16 atm. TheLM-LCX stent struts were opened via a wire through

the stent struts into the LAD with a Maverick 2.5 mm� 20 mm balloon at 16 atm. Next, a Taxus Liberte 3.0mm � 24 mm stent was deployed from the midLMCA to the proximal LAD at 14 atm, the LM-LADstent strut was opened to the LCX with a Maverick 3.0mm � 20 mm balloon at 16 atm. A final kissing bal-loon inflation was performed with a Maverick 3.5 mm� 20 mm balloon in the LCX and a Maverick 3.0 mm� 20 mm balloon in the LAD, both inflated at 14 atm.The final IVUS study showed a minimal stent area(MSA) of 16.0 mm2 in the distal LMCA, but a slightlyunder deployed stent in the proximal LMCA, it wasredilated with a Quantum Maverick 4.5 mm � 8 mmballoon (Boston Scientific) at 20–22 atm. A final TIMI3 distal flow was achieved in all three vessels. TheIVUS study showed an MSA of 7.40 mm2 in LADostium, and an MSA of 10.38 mm2 in the LCX ostiumwith good stent expansion and apposition. The ostiumof intermediate branch was not compromised after Cu-lotte stenting. After the procedure, the patient was dis-charged with uneventful course and continued on aspi-rin and clopidogrel. Six months later, the patient experi-enced recurrent chest pains for 2 days. A 12-leadelectrocardiogram showed nonspecific T-wave changes.A follow-up angiogram was performed, revealing a pat-ent LMCA trifurcation stenting site, focal intent reste-nosis (ISR) at the LCX distal stent and borderline ISRat LCX ostium, which were redilated with a Sprinter3.0 mm � 15 mm balloon (Medtronic) at 18 atm.

The LCX distal ISR site was treated with a TaxusLiberte 3.0 mm � 16 mm stent at 20 atm, with goodfinal angiographic results and TIMI 3 distal flow.

Fig. 1. Left coronary artery angiogram showed trifurcated left main with a significantsteno-sis at its distal body extending to proximal LAD, LCX and intermediate branch (A) anteriopos-terior view, (B) left anterior oblique caudal view.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

680 Hussein et al.

IVUS examination showed an MSA of 7.78 mm2 atthe treated segment. The patient was discharged afteran uneventful 2-day hospital stay and maintained ondual antiplatelet therapy for additional 12 months, thepatient was asymptomatic and MACE free at a 16-month out patient follow-up.

DISCUSSION

This case report provides relevant evidence of thefeasibility of a transradial approach using a 6F guidingcatheter with IVUS guidance for PCI treatment ofLMCA trifurcation lesions. Trifurcating coronary artery

disease is a complex atherosclerotic process involvingthe origins of one or more of the three SB arising fromthe main coronary artery vessel or main trunk (MT),with or without involvement of the MT itself [4]. Tri-furcation lesions are more difficult for preserving thepatency of the ostium of each branch than bifurcationlesions. Previously reported data for coronary interven-tion in trifurcation lesions described the use of 8F and9F guiding catheters through a transfemoral approachthat accommodated different complex stenting strat-egies. However, these strategies did not improve theoutcome of trifurcation lesion PCI, and they resulted ina MACE rate of 33% [7]. As the use of a 5 or 6F

Fig. 2. Sequential balloon inflation at LM to (A) proximal LCX, (B) proximal LAD, (C) proximalintermediate branch using Maverick 2.5 mm 3 20 mm inflated at 12 atm at each branch, (D)follow-up angiogram post balloon dilatation.


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arterial sheath is preferred by many interventionaliststo reduce bleeding complications, few techniques havebeen described to improve angiographic outcomeswhen using a 6F guiding catheter for simultaneouslytriple-balloon inflation with slender devices of 0.010-in. guide wires and 0.010-in. wire-compatible balloon

catheters, or triple balloon-on-a-wire or ‘‘menage atrois’’ coronary angioplasty [8,9]. At the TranscatheterTherapeutics Meeting, San Francisco, USA (2009), anovel technique of utilizing two guiding catheters viatwo simultaneous access sites to engage the coronaryostia was presented. Our case report showed that using

Fig. 3. (A) Zoomed LCA angiogram post balloon dilatation ‘‘spider view’’. Intravascular ultra-sound imaging showing the MLA & MLD at (B) near ostial LM. MLA and residual stenosis at(C) distal LM, (D) ostial LAD, (E) pull back from LAD to LM showing the patency of intermedi-ate branch orifice (arrows), (F) ostial LCX.

Fig. 4. (A) Zoomed LCA angiogram post stenting ‘‘spider view’’. Intravascular ultrasoundimaging showing the MLA and residual stenosis at (B) distal LM (C) ostial LAD (D) at distalLM to LAD showing the patency of intermediate branch ostium with stent struts crossover(arrows) (E) ostial LCX.


682 Hussein et al.

IVUS post both, sequential balloon dilatation of the tri-furcation branches and Culotte stenting of the largerbranches of the LAD and LCX, excluded plaque or ca-rina shifting to the smaller intermediate branch onIVUS study, proving that the described technique isuncomplicated and effective.

LIMITATION OF 6F GUIDING CATHETER

When using this technique, careful handling is essen-tial to avoid tangled guide wires with limited transmis-sion of torque; we were able to overcome this limita-tion by the use of an Ikari guiding catheter with a largeinternal lumen diameter to provide sufficient support.A possible risk of this procedure involves the potentialcompromise of the intermediate branch of the LMCAnecessitating the use of slender devices or a shift to the7F system.

In conclusion, the use of a 6F guiding catheter viathe transradial approach with IVUS guidance duringPCI is a feasible and effective method of treatment fortrifurcation LMCA lesions in selected cases.

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Fig. 5. Left coronary artery Final angiogram showing trifurcated left main with satisfactor-yangiographic result post two stent strategy using 6F guiding catheter via transradialapproach withsupport of IVUS guidance (A) RAO-caudal view, (B) Spider view.


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transradial complex left main trifurcation intervention

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