PCI of CTO LAD-D1 Bifurcation using Mini-Crush Technique – April 2023
CASE & Plan:
59-year-old male presented with CCS III angina and positive stress MPI for MV ischemia. A Cardiac Cath on March 27, 2023 revealed 2 V CAD: mid LAD CTO with 95% LAD-D1 bifurcation (1,1,1), 80% LCx-OM1, FFR non-significant RCA disease with SYNTAX Score of 27. Patient underwent successful intervention of LCx-OM1 using Xience DES. Patient is now planned for imaging guided PCI of CTO LAD-D1 bifurcation using Mini-Crush technique.
QThe real challenge in the case turned out to be the diagonal branch?
A.Yes Diagonal branch was expected to be challenging and really was. Final results were excellent after using the Fighter wire.
QWe do not have the Fighter wire, what else should work in such angulated lesion?
A.Whisper ES or Sion Blue are the other alternative wire choice in angulated tortuous lesions.
QWas a cutting balloon an option for the diagonal?
A.Yes cutting balloon is best for non aorto-ostial lesions like Diagonals and OMs. But cutting balloon is unlikely to be advanced in the very tortuous angulated lesions and just NC balloon will suffice; that is what was done in this pt.
QPlease explain more about Fighter wire?
A.Fighter Guidewire made by BSC Inc, is a polymer jacketed hydrophilic wire for loose tissue tracking, probing complex angulated lesions. It’s properties are mostly similar to Asai’s Whisper Guidewire but slightly strong body support for easy advancement of the devices in the angulated lesions.
QIt seems Mini Crush is now your preferred technique?
A.Yes for planned 2 stent approach for bifurcation lesions at Sinai, MiniCrush technique predominates (70-75%), DK-Crush in 10-15%, Step-Crush or reverse Crush in 8-10% and Cullote stents in 3-5% of cases.
QWhy do you prefer it over DK crush?
A.We prefer MiniCrush over DK-Crush mainly due to simplicity and 3 fewer steps. Also we never had problem of final KBI in MiniCrush techniques which apparently is being hailed as easier to do in DK-Crush over MiniCrush.
QHave you performed your own analysis about the two techniques?
A.Yes we are currently in the process of evaluating 1845 consecutive Bifurcation PCI at MSH with 2 Stents in last 5 years; reviewing all the angiographic and clinical data. Then only we will claim superiority or equality of two bifurcation techniques.
QWhat is the best way to use your Apps? Before doing a case?
A.In my opinion, best way to use our cardiology Apps, is first select the interested subject and then go thru the App with all its detailed points; before using it in the case. Then only, one will know what are its contents so that one can go back to the App resource in particular angiographic scenario, troubleshooting or complications; in this scenario, App is useful during the case.
QAre some operators finding it useful to simultaneously use the Apps?
A.Yes many interventionalists have commented on the utility of the App use, simultaneously during the case as a particular technique procedure continues to loop during the case.
QAre new Apps being developed?
A.Many more new Apps like IVUSAid, Coapt risk score. BCIS chip score are in development.