Proximal Side Optimization: A Modification of the Double Kissing Crush Technique

Abstract

Coronary bifurcations with significant lesions >10 mm in the side branch (SB) are likely to require two-stent treatment techniques. To date, double kissing Crush (DK-Crush) stenting has demonstrated higher rates of final kissing balloon inflation and better clinical outcomes. The technical iterations that lead to optimal clinical outcomes have been attributed to the first kissing balloon that repairs the distorted proximal segment and fully expands the orifice of the side stent. One potential caution, which relates to all Crush techniques, is the possibility of the guidewire crossing in an inappropriate position toward the Crushed SB stent. When this occurs, the SB stent may be further Crushed, leaving the ostium uncovered, which potentially negates the benefit of the Crush technique. In our experience, proximal side optimization (PSO) during DK-Crush stenting ensures stent size ‘accommodation’ to the larger vessel diameter in the proximal segment and better strut apposition to the wall, which is particularly important in the ostial segment. The benefits of this additional modification of the established DK-Crush technique are reduction or elimination of the risk of SB stent distortion, increase of the space of optimal wiring, and avoidance of guidewire advancement under the stent struts, even in unfavorable anatomies with extreme angulation. The author describes a step-by-step approach of a proposed PSO technique, which is easy to perform without any additional procedural time or costs.

Optical Coherence Tomography to Assess Proximal Side Optimization Technique in Crush Stenting

“…Ten bifurcation lesions, all Left Anterior Descending Artery, Diagonal Branch Bifurcation (LAD-D) Medina 1.1.1, with long (>10 mm) and severe stenoses (>75%) of the long (>75 mm) SB, were randomly assigned in a 1:1 ratio to either Double Kissing Crush bifurcation stenting (DK Crush) of the non-PSO group ( 4 ), or DK Crush in PSO modification of the PSO group ( 1 ). All PCI procedures were angiography-guided and all lesions were treated using Xience V (Abbott Vascular, CA, USA) DES.…”

“…The Proximal Side Optimization (PSO) is the last proposed technique adjustment of DK crush, based on a Side Branch (SB) stent post-dilatation prior to the crush ( 1 – 3 ), Supplementary Material . Given the high resolution and the capability for three-dimensional (3D) reconstruction, we sought to use Optical Coherence Tomography (OCT) to further explore the potential intraprocedural benefits of this modification in a series of patients treated by two-stent DK Crush approach for true bifurcation lesions.…”

European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions

“…The stent should protrude into the MV but such protrusion should be limited to 2–3 mm. Placement of a balloon in the MV to crush the SB stent (size selected in order to achieve appropriate crush, see below). The SB stent is inflated whilst the MV balloon is kept uninflated in the MV. After SB stent deployment, the balloon of the stent might be slightly pulled back and repeated inflation at high pressure can be performed (the balloon inside the MV is still kept un inflated during this phase). This step (called “SB optimization” by Dr Francesco Lavarra in his oral communication at EBC meeting 2018 35 ) is aimed at achieving the best stent apposition and expansion at the SB ostium. The SB stent delivery balloon and the SB guidewire are removed. The MV balloon is positioned at the level of the SB take‐off and high pressure inflation is performed in order to crush the stent struts protruding inside the MV (“balloon‐crushing”). The balloon size should be adjusted according to amount of atherosclerosis and MV size, but bench tests show that POT technique is needed to achieve complete stent crushing. The SB is rewired using a guidewire with an appropriately shaped tip aiming at crossing the SB ostium through a non‐distal cell 36 …”

Fundamentals of percutaneous coronary bifurcation interventions

“…The stent is positioned protruding 2-3 mm into the PMV (Figure 12A ); (3) A balloon sized to the PMV is positioned in the MV to crush the stent later. This balloon will be kept uninflated until the crushing procedure (Figure 12A ); (4) After the SB stent is implanted, a new method called the “proximal side optimization” described by Lavarra[ 97 , 98 ] and considered useful by the EBC[ 25 ] may be performed. In this method, the stent balloon is slightly withdrawn and inflated at 4-6 atm higher than the nominal pressure (Figure 12B ); and after removing this balloon, a new NC balloon (0.25-0.5 mm larger than the SB stent) is again inflated in the protruding part of the stent and the SB ostium (Figure 12C ).…”