Author + information
- Tse-Husan Yang1,
- Wei-Chun Huang1,
- Chin-Chang Cheng1,
- Cheng-Hung Chiang1,
- Feng Yu Kuo1,
- Guang-Yuan Mar1 and
- Chun-Peng Liu1
Patient initials or identifier number
Relevant clinical history and physical exam
A 49 years old man complained about worsening chest tightness and effort related dyspnea in present weeks. He has a history of smoking, hypertension, dyslipidemia, and previous ACS with triple-vessel disease, treated by percutaneous coronary intervention with stent over LAD, LCX, and RCA.
Relevant test results prior to catheterization
The myocardial perfusion scan revealed ischemia over antero-septal and infero-lateral wall.
Relevant catheterization findings
The coronary angiogram revealed LAD-proximal 90% stenosis; LCX-distal 90% in-stent restenosis (ISR), and RCA-middle, -distal 80% stenosis,-PDA: 90%, -PLV-orifice 95% stenosis and distal PLV ISR with total occlusion. The Medina classification of RCA-D, -PLV, and -PDA bifurcation is 1.1.1.
We performed the procedure with a 6Fr sheath via a right radial artery. SAL guiding catheter used to engage RCA orifice. The RCA-PDA was crossed with Fielder FC 0.014” guide wire. We try to cross the RCA-PLV lesion with reverse wire technique, but failed to cross CTO lesion. Therefore, we performed the OCT for evaluate the vessel condition, and there were diffuse arthrosclerosis with in-stent restenosis over RCA-PDA lesion on the image. Balloon dilatation was performed for RCA-M, RCA-D, RCA-PDA lesions, and residual stenosis still noticed by QCA method. A Bioresorbable Vascular Scaffold (BRS) deployed over RCA-PDA lesion. However, after post-dilatation, the patient suffered from chest pain with ST-elevation, and hypotension noted due to jail of RCA-PDA. After another two BRS implantation over RCA-M and RCA-D, we tried to rewire the jailed lesion due to BRS implantation. Fortunately, the PLV lesion was crossed with a Fielder FC 0.014” guidewire via support of crusade catheter. Finally, the CTO lesion was crossed via Ultimate Bro 3 wire under support of fine cross micro catheter. After dilatation of bifurcation, a DES delivered smoothly via cell of BRS stent. Then, combination of proximal optimization technique and snuggle kissing technique, also called as T-stenting and small protrusion (TAP) technique, were used. The final result was optimal without complication.
The application of BRS remains challenging in bifurcation lesion, especially 2 stents technique. Here, we demonstrated a case using combination of BRS and DES via T-stenting and small protrusion (TAP) technique in a complicated PCI lesion.