Case 217: Manual of PCI - Shape It

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[00:00:00][snorts] >> Hi, this is Masitaguell, Nikoulla Forte and Manos Brilakis presenting case 217 for the manual of percutaneous coronary interventions.

[00:00:10]This is a case illustrating sequential troubleshooting for tackling a left main trifurcation lesion.

[00:00:19]The patient was a gentleman who had previous PCI of the right coronary artery and then he was found to have a significant trifurcation left main disease but due to some comorbidities uh treating that was delayed until later on.

[00:00:33]He eventually was turned down for bypass because of frailty and was sent for PCI of the left main trifurcation.

[00:00:41]This is the baseline angiogram.

[00:00:43]We do have uh three major branches coming out of the left main, large circumflex with an acute retroflex angle.

[00:00:51]Have a large ramus branch and we have the LAD and all three branches as well as the left main have significant disease with the left main being diffusely diseased.

[00:01:02]So, how to approach this?

[00:01:04]Our first approach was to dilate all three vessels and then uh try to uh do a provisional strategy potentially with uh kissing balloons.

[00:01:18]We first placed a wire into the ramus, that was easy and then placed a wire in the LAD but trying to get a wire into the circumflex was extremely challenging because of the angulation.

[00:01:30]We tried polymer-jacketed wires including a Seal on Black.

[00:01:34]That did not work. We tried the Suo 3.

[00:01:37]We tried a Sasuke dual lumen, that did not work.

[00:01:41]We tried the reversed the reversed wiring technique, the hairpin technique going into the ramus and coming back. We tried an angulated microcatheter called the Shape It which is one we can shape ourselves but didn't work and during all those attempts the patient suddenly had a loss of flow into the ramus.

[00:02:01]So, he had a dissection of the ramus.

[00:02:04]Fortunately, we did have a wire from before.

[00:02:07]So, the next step was to quickly place the stent. We placed a 3.0 stent. And that stabilized the ramus. But, of course, now it's even worse because we have a stent all the way to the ostium of the circumflex. So, getting there was much more complicated.

[00:02:24]We also had some reduction of flow in the LAD and we ballooned the proximal LAD.

[00:02:31]And then did multiple attempts once again to try to go into the circumflex.

[00:02:35]We did use various microcatheters. We did use the Supercross 90 where unfortunately did not have the 120.

[00:02:45]We did use a blocking balloon into the ramus, but that didn't work.

[00:02:49]Reverse wiring was getting caught into the struts. And this is a shaping microcatheter along with a Pilot 50 wire.

[00:02:58]A lot of attempts. This microcatheter you can see, but it's a monorail catheter.

[00:03:03]And we can see the wire is going the wrong direction.

[00:03:06]Um we had intermittent puffing to see where we're going. In this case, the wire seems to be subintimal. So, have a dissection the left main. Pulling back, try to redirect.

[00:03:17]And then eventually after multiple attempts, it literally took 3 hours from the beginning of the case where finally the wire went into the circumflex branch.

[00:03:27]So, after this our plan was now to stent across into the circumflex. That was the toughest branch to wire. So, we pre-dilated it.

[00:03:36]Fortunately, it expanded nicely.

[00:03:38]And then we placed a 3.5 mm drug-eluting stent from the left main going into the circumflex jailing the ramus that had been previously stented and also jailing the proximal LAD.

[00:03:51]But, as we can see, we already have some significant disease in the ostium of the ramus and also residual disease in the proximal LAD.

[00:04:01]Also, there is haziness into the left main.

[00:04:05]So, we do have a at the area of the dissection from before, we still have an area of haziness. So, this did not look satisfactory to us.

[00:04:16]Therefore, we decided to place stents in the ramus and the LAD.

[00:04:22]We first rewired after doing proximal optimization. So, we rewired both the ramus as well as the LAD.

[00:04:30]And then did kissing balloon inflation sequentially.

[00:04:33]>> [snorts] >> And then did place drug-eluting stents both into the ramus, but also into the LAD.

[00:04:45]And this is how it looks after placing the stents, which is not an optimal result. And we still have this hazy area, which made us wonder whether we missed the ostium of the LAD.

[00:05:00]Um we did IVUS and we decided to place an additional stent. So, this is now an additional 3.5 by 15 mm drug-eluting stent placed from the ramus all the way into the left main.

[00:05:14]And then we did intravascular ultrasound.

[00:05:18]The vessel more distal looks okay, but as we come towards the left main, there is a suboptimal result. There seems to be some tissue uh planes uh where we enter into the vessel.

[00:05:35]Also, the ostium of the LAD did not look optimal and that is why we ended up placing an additional drug-eluting stent. This time we're going again from the left main all the way into the LAD.

[00:05:45]So, we now we have a stent all the way from the ramus into the left main, which is in a culotte fashion. And this is a second culotte. This time, the culotte is happening between the LAD and the left [snorts] main stent.

[00:06:02]And it does look better.

[00:06:04]We do have good flow into the LAD. We have good flow in the ramus as well as the circumflex.

[00:06:10]However, there's still that area of haziness within the left main.

[00:06:16]Which is better than before. Then after doing ultrasound again, IVUS, we decided to stop it, and this is how the IVUS looked like.

[00:06:25]Um we're coming back from the This is from the ramus, and uh when we get to the ostium of the vessel, there is a little tissue plane, but there are stents already that had been placed before covering this.

[00:06:39]And the left main itself is fairly large with a good result.

[00:06:47]So, this was the final result. Multiple Multiple lessons from this case. The first one is about having a workhorse wire in a vessel when you're trying to rewire the side branch. In this case, we dissected the ramus while trying to wire the circumflex, and having the wire there allowed the bailout with a stent placement.

[00:07:07]Second, and a big part of the case, was wiring an angulated side branch.

[00:07:13]We tried different wires, including polymer wires.

[00:07:17]We tried a Sasuke to lumen.

[00:07:19]We tried a Twin Pass. We tried a uh angulated We tried a Supercross 90, which doesn't didn't give enough angulation. We unfortunately did not have the 120, which is the one we typically use.

[00:07:31]And we tried the Shape It, which is the one you can shape, and eventually this was the one that allowed advancement of a Pilot 15 to the vessel.

[00:07:39]We also tried the blocking balloon into the ramus. that didn't work and also we tried a reverse guide wire. The lesson here is persistence is important and having different equipment and tools can be critical to wire this challenging lesions.

[00:07:56]Provisional is the standard way to stand by for occasions if possible but in this case we had significant residual disease in the LAD and the ramus therefore we had to place more stents.

[00:08:09]We did multiple rounds of cool lot and the issue there was that despite all the stents and despite being certain after the final round that we had stents all the way from the left main into both the LAD as well as the ramus and the circumflex there was still some area of haze and some tissue plane into the trifurcation and this likely represented carina shift.

[00:08:34]But once again we had done everything and we didn't think that any more time or any more stents or balloons would help and that's why we accepted this as a final result. Thank you.