Step by step approach in a difficult bifurcation PCI

Introduction: A coronary bifurcation lesion occurs at or near a division of a major coronary artery. The characterization of bifurcation lesions involves the evalua-tion of the morphology of the lesions in three important anatomical segments: (1) the main proximal branch (main branch – MB); (2) distal main branch and (3) lateral branch (side branch –SB). Numerous classifica-tion schemes have been proposed to describe coronary bifurcation lesions. The simplest and most widely used is the Medina classification, which assesses the severity of plaque according to the presence („1“) or absence („0“) of stenosis in the proximal, distal main vessel and lateral branch, a plaque being considered significant when the stenosis is over 50% of the vessel lumen. The treatment of bifurcation lesions in atherosclerotic coronary heart disease is associated with a high rate of intraprocedural complications due to the complexity of the intervention, and compromises approximately 20% of percutaneous coronary interventions. The SYNTAX score can be used to determine which patients may be-nefit from interventional vs. surgical revascularization. Clinical data have demonstrated over time the benefits of the „Double Kissing“ (DK) Crush technique for lesi-ons involving coronary bifurcation over other stenting methods.

Case presentation: We present the case of a 42-year-old man, smoker, hypertensive, without drug treatment at home, who is hospitalized urgently for episodes of previous chest pain with typical angina, recurrent episodes in the last 48 hours and ECG changes in the infe-rior territory, without elevation of myocardial necrosis enzymes. Coronary angiography is performed showing bivascular atherosclerotic coronary involvement with critical stenosis of the left circumflex (LCX) and left an-terior descending artery (LAD) at the bifurcation with the first diagonal branch (DG1) (Medina type 0-0-1) and with the second diagonal branch (DG2) (Medina type 0-1-1). The patient has a SYNTAX score of 12 and it is decided to perform percutaneous coronary angio-plasty with the implantation of a drug-eluting stent in LCX to the main marginal branch and simple balloon angioplasty (POBA) in the proximal part of the first diagonal branch of LAD. It is decided the subsequent revascularization in a second procedure of the LAD bifurcation lesion with DG2 by the „Double Kissing” Crush technique, with a very good final result, without procedural or post-procedural complications.

Particularities of the case: Multivascular coronary heart disease in young patients and the decision of complete revascularization by interventional vs. surgical methods. DK Crush technique of interventional coronary revascularization of bifurcation lesions.


ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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