Stenting of LAD-diagonal bifurcation – from simple to complex procedure

Introduction: Bifurcation lesions are frequent in cur-rent practice accounting for almost 20% of interven-tional procedures. Treatment with drug eluting stents remains difficult and complex, lesions are associated with a less favorable long-term outcome compared with simple ones.
Case presentation: We present the case of a 56 year old man, smoker, diabetic, hypertensive, with an inferior myocardial infarction treated with angioplasty 3 years ago, admitted in the Cardiology Department of Cardi-ovascular Disease Institute Iasi, for constrictive chest pain during low intensity exercise relieved by 2 sprays of nitroglycerin. At admission the patient is stable, in sinus rhythm, with EKG criteria for chronic inferior myocardial infarction. Echocardiography revealed left ventricular inferior wall hypokinesis with a mild decre-ase in global systolic function. Coronarography showed no stent resteonsis of the previous stent and a bifurcation lesion of anterior des-cending artery and diagonal forming a 95% long di-ffuse stenosis of the descending artery and a 50% os-tial stenosis of the first diagonal. Provisional stenting of the left anterior descending artery is performed. A long type E dissection (NHLBI classification) is seen from the ostium of the diagonal to the distal part of it. A second stent using the T and protrusion technique is implanted in the diagonal with a final kissing dilatation in both branches with good result and no residual stenosis in both vessels. At the 1, 3, 6 months follow-ups the patient was asymptomatic with good exercise tolerance, but the long term prognosis is unfavorable due to multiple stents and uncontrolled cardiovascular risk factors.
Conclusions: Bifurcation lesions present with a varia-ble morphology and are associated frequently with in-traprocedural complications. We chose switching from provisional to complex angioplasty with T and protru-sion because this technique has good ostial coverage, has minimal overlapped stenting layers and forms a ne-ocarina with only one single layer, reducing the long-term risk of in stent restenosis.

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)