PCI of Proximal LAD and Proximal LCx using ‘Step Crush’ Technique – October 2022

Case & Plan: 70-year-old male presented with CCS Class III angina and positive SPECT MPI. A Cardiac Cath on September 15, 2022 revealed 3 V CAD: 80% long segmental proximal RCA, 80% calcified proximal LAD, 90% distal LAD, 70-80% proximal LCx with normal EF and SYNTAX Score of 22. Patient underwent successful PCI of proximal RCA using (one Xience) DES. Patient is now planned for staged PCI of prox LAD and prox LCx using imaging guided plaque modification and ‘Step Crush’ technique.

Q&A

Q How is step crush different from routine mini crush as we know it?
A. Overall mechanistically both Step-crush and Mini-crush have final end results of functioning of 2 stents with main advantage of Step-crush is ability to do the procedure with 6Fr guide while Mini-crush requires at least 7Fr guide as both stents have to be advanced together at same time.
Q And different from the DK-crush?
A. Step-crush is similar to DK-crush except 2 less steps of kissing balloon dilatation. All 3 techniques provide excellent angiographic results with DK-crush having slightly better MLD of the SBr stent.
Q Is it more applicable to use with wrist access?
A. Both Mini-crush and DK-crush can be done via 6Fr guide and hence can easily be done with radial approach. Mini-crush requires 7Fr guide, which many times is difficult via radial access.
Q What are its perceived benefits?
A. There has not been any direct comparisons of all 3 types of crush techniques, but all seems to be beneficial in efficacy and safety. Obviously DK-crush has been studied extensively with excellent long-term results and superior to Culotte and Provisional stent approaches. Hence DK-crush has made to the ACC/AHA Revascularization guidelines as Class IIa recommendations in treatment of bifurcation stenting involving medium-large SBr.
Q And clinical data supporting it?
A. We have few registry reports of clinical efficacy and safety of both Step-crush and Mini-crush stent techniques.
Q Where would you avoid it?
A. Step-crush is not recommended if SBr is small (<2.5mm) and/or if SBr angle is <45degree.
Q Where do you see the role of the ScoreFlex atherotomy device?
A. ScoreFlex balloon atherotomy is good device for treatment of mild-mod calcified lesions and ISR. It’s mechanism is similar to AngioSculpt device and we have replaced AngioSculpt device with ScoreFlex in our lab.
Q How often do you use it?
A. We use approximately 60 Wolverine cutting balloon, 40 ScoreFlex, 40 IVL, 60 Rota, 8 OA and 3 ELCA per month. Many of these devices are used in conjunction in treating complex calcified lesion.
Q Would it have merit for endovascular disease management?
A. Yes large size ScoreFlex is also used for endovascular interventions.
Q Where do you see the use of ultra thin strut stents in the future?
A. Ultra-thin strut stents will continue to get better in terms of lower elastic recoil and excellent safety records.

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