Author + information
- Fa-Chang Yu1
Patient initials or identifier number
Relevant clinical history and physical exam
A 78 year-old man was a smoker and received medication treatment for hypertension and hyperlipidemia. He had intermittent effort angina while climbing the mountain and visited cardiologist's clinic where myocardial perfusion scan was done. However, he was sent to ER due to worsened chest pain with diaphoresis, and elevated cardiac enzymes were noted. Then he was admitted in CCU for NSTEMI.
Relevant test results prior to catheterization
EKG showed sinus rhythm with diffused T wave inversion. Heart echo showed preserved LV systolic function; regional wall motion abnormality in anterior and apical wall, and mild MR, TR. Myocardial perfusion scan showed myocardial ischemia in anterior, apical and inferoposterior walls.
Relevant catheterization findings
CAG showed a dominant RCA without significant stenosis and a critical calcified lesion at m-LAD which was functional total occlusion. The collateral flow was form d-LCX to d-LAD. The donor vessel, p-m-LCX also had 80% stenosis. It’s a true bifurcation consisted with m-LAD and septal branch (Medina 1,1,1).
We treated the donor vessel, LCX first with DES deployment in p-m LCX. Single-stent strategy with PSP/PKP or two-stent strategy with culotte/MiniCrush was reasonable to treat true bifurcation with small angulation. However, to deploy a stent in septal branch was currently not recommended because of easily crush and fracture. We decided to deploy ASSESS bifurcation stent at m-LAD to cover the ostial lesion of septal branch without further metal inside.
The Wizard 3 guidewire can not pass the critical lesion at m-LAD until supported by Crusade catheter and we also put Sion in septal branch successfully. Unexpectedly, the AXXESS stent was entrapped at d-LAD due to heavy calcification and was drawn out of the sheath. Finally, we did successfully troubleshooting by balloon-traction for one-sided entrapment of Axxess stent and completed PCI procedure for complex bifurcation lesion.
The PCI strategy for complex bifurcation lesion between LAD and septal branch is not easy. Dedicated strategy with Axxess bifurcation stent can simplify complex bifurcation under careful selection. Although stent dislodgement is very troublesome in any kinds of scaffold, balloon-traction technique is an effective method for one-sided entrapment of Axxess (self-expansible stent).