Buddy-Balloon Technique for Final Kissing-Balloon Dilatation After Crush Stenting of the Left Main Coronary Artery

Abstract: Background. Crush stenting mandates a final kissing-balloon technique (KBT) for a better clinical outcome; however, recrossing the 2 overlapping stent struts with the balloon catheter is technically challenging. Objectives. The efficacy of the buddy-balloon technique for facilitating completion of the final KBT during crush stenting of the left main coronary artery (LMCA) was evaluated. Methods. The records of 38 consecutive patients who underwent crush stenting for a lesion in the distal LMCA from January 2005 to December 2009 were retrospectively reviewed. Results. In 23 of the 38 patients, recrossing the balloon catheter to the left circumflex artery (LCX) was difficult, even with appropriate backup support from the guiding catheter. To enhance recrossing of the balloon catheter, the buddy-balloon technique was used, which resulted in the successful completion of the final KBT in 21 patients (91.3%). For the 2 patients in whom the technique was unsuccessful, the final KBT was subsequently achieved by performing the buddy-balloon technique in the LCX using a 1.5 mm balloon catheter. The overall success rate of the final KBT was 100%. One year after the procedure, target lesion revascularization (TLR) rate of these 23 cases showed no significant difference when compared with the TLR rate of patients for whom this technique was not needed. Conclusion. The buddy-balloon technique is a suitable option when used in the context of crush stenting in patients with lesions of the distal LMCA.

J INVASIVE CARDIOL 2012;24:38-41

Key words: percutaneous coronary intervention, drug-eluting stent, two-stent strategy

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Crush stenting is a major breakthrough in the revascularization of lesions in the distal left main coronary artery (LMCA).¹ However, this technique carries a poor prognosis when the final kissing-balloon technique (KBT) has failed. In this study, we retrospectively evaluated the efficacy of a buddy-balloon technique2 for patients in whom the final KBT failed because the balloon could not cross the stent strut in the ostium of the left circumflex artery (LCX).

Methods

Patient characteristics and crush stenting procedure. Between January 2005 and December 2009, a total of 38 consecutive patients, including those with acute coronary syndrome or cardiopulmonary arrest on arrival, underwent crush stenting with the Cypher stent (Cordis Corporation) for the LMCA. Of these 38 patients, 23 required the buddy-balloon technique to achieve the final KBT, and their results were analyzed retrospectively and compared with those of 15 patients who did not require this procedure. Detailed characteristics of the patients and procedures are described in Tables 1 and 2.

Procedure. The standard procedure used for this technique is illustrated in Figure 1. After crush stenting, we rewired to the side branch, usually with a dual-lumen catheter such as the Multi-functional Probing Catheter (Boston Scientific) or Crusade Catheter (Kaneka) to avoid wire migration under the stent strut in the proximal LMCA. Then, two semi-compliant balloon catheters, which were usually used for predilatation and the sizes of which were decided according to the reference diameter of each branch, were introduced into the lesion for the final KBT. For those patients who did not undergo predilatation or received predilatation with a single balloon catheter, we produced new balloon catheter(s) for the final KBT. When the balloon catheter used for the side branch was stuck at the ostium of the LCX (Figure 1A), both balloons were inflated simultaneously with the LCX balloon catheter in a stuck position (Figures 1B and 1C). Inflation of the balloon catheter in the main branch was carried out at nominal or high pressure (usually at 8-12 atm) at the same time as the balloon catheter in the side branch was under nominal pressure (2-6 atm). This procedure changes the angle of the tip of the balloon catheter stuck in the side branch and widens the stent strut at the ostium of the LCX. After the balloon was inflated several times, it eventually crossed the stent strut (Figure 1D). When the buddy-balloon technique failed, a 1.5 mm balloon catheter was introduced into the LCX, and the same procedure was performed again until the balloon crossed the stent strut. Angiograms of a typical case are presented in Figure 2. Scheduled angiographic follow-up was conducted between 9 and 12 months after the index procedure.

Results

In all 23 patients who required the buddy-balloon technique, the final KBT was successfully performed, including in 2 patients who required an additional buddy-balloon technique with a 1.5 mm balloon catheter to cross the stent strut in the LCX after failure to cross the lesion with the initial balloon catheter and the 1.5 mm balloon catheter without the buddy balloon technique. Of these 23 patients, one developed subacute stent thrombosis, and balloon angioplasty under extracorporeal membrane oxygenation and intra-aortic balloon pumping were performed; the patient survived. The target lesion revascularization (TLR) rate at 1 year in the 23 patients who underwent this technique was 21.7%, and no significant difference was observed when compared with the TLR rate in patients for whom the technique was not required (Table 2).

Discussion

In this study, we demonstrated the efficacy of the buddy-balloon technique for distal LMCA lesions in patients in whom the final KBT failed with a standard technique. All 23 patients successfully underwent the final KBT with this procedure. Although the final KBT is an important additional procedural step of crush stenting, recrossing the 2 overlapping stent struts with the balloon catheter has been technically challenging. In their original article, Colombo et al reported that additional KBT was performed in 40% of patients.¹

Failure of the final KBT carries a poor long-term prognosis. To date, several studies have suggested that one of the main predictors of an adverse outcome of crush stenting is failure of the final KBT.^3,4 This finding can be attributed to several features of crush stenting. First, when the protruding struts of the stent implanted in the side branch are crushed against the wall of the stent in the main branch by the balloon or the stent in the main branch, the stent in the side branch may cause distortion, which results in incomplete apposition of the stent strut and uneven delivery of drugs to the lesion. Second, lack of the final KBT is associated with failure to attain full expansion of the stent in the proximal side of the main branch where stenting comprises 3 layers. Third, the remaining 2-layer stent strut floating in the bloodstream in the ostium of the side branch may increase the potential risk for thrombus formation and restenosis.⁵

Several procedures have been proposed to enhance completion of the final KBT. Introducing a new small-profile balloon or the use of an anchor balloon technique is often applied after failure of standard techniques in an attempt to cross the stent strut. The double-kissing crush technique also facilitates the final KBT.^6,7 This technique is reported to achieve even better long-term outcomes when compared with conventional techniques. Postdilatation in the main branch with a balloon at high pressure is also recommended.⁴ These additional procedures have improved the success rate of the final KBT, and in a recent paper, Colombo et al⁸ reported that the success rate of the final KBT after crush stenting was 92.1%. This buddy-balloon technique facilitates recrossing of the balloon catheter by changing the structure of the stent strut in the ostium of the LCX.⁹ It also allows for a more favorable vector of force transmission to enhance recrossing.²

In this study, all patients successfully underwent the final KBT; however, the described technique may have some limitations. First, although we used dual-lumen catheters to avoid wire migration for rewiring to the LCX in 22 patients (95.7%), some concerns regarding the wire being introduced behind a strut still exist. In that case, excessive force to deliver with this technique may destroy the stent and/or lead to abrupt closure in the acute phase. Second, such excessive force may also damage the surface of the polymer coat, which may affect long-term clinical outcomes. The results of this study, however, show that the buddy-balloon technique did not affect the 1-year TLR rate when compared with the TLR rate in patients who did not require this technique.

In conclusion, in view of the acute success and long-term benefits shown in this study, as well as the cost-effectiveness of the procedure, the buddy-balloon technique is a suitable option for completing the final KBT after crush stenting.

Acknowledgment. We gratefully acknowledge the technical guidance and advice of Dr. Kazuaki Mitsudo with respect to the procedures described in this manuscript.

References

1. Colombo A, Stankovic G, Orlic D, et al. Modified T-stenting technique with crushing for bifurcation lesions: immediate results and 30-day outcome. Catheter Cardiovasc Interv. 2003;60(2):145-151.
2. Gunalingam B, Chan RY. A novel buddy balloon technique to recross a T-stented bifurcation. Catheter Cardiovasc Interv. 2009;74(1):103-107.
3. Ge L, Airoldi F, Iakovou I, et al. Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. J Am Coll Cardiol. 2005;46(4):613-620.
4. Hoye A, Iakovou I, Ge L, et al. Long-term outcomes after stenting of bifurcation lesions with the “crush” technique: predictors of an adverse outcome. J Am Coll Cardiol. 2006;47(10):1949-1958.
5. Chen SL, Zhang JJ, Ye F, et al. Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents. Eur J Clin Invest. 2008;38(6):361-371.
6. Collins N, Dzavik V. A modified balloon crush approach improves side branch access and side branch stent apposition during crush stenting of coronary bifurcation lesions. Catheter Cardiovasc Interv. 2006;68(3):365-371
7. Chen S, Zhang J, Ye F, et al. DK crush (double-kissing and double-crush) technique for treatment of true coronary bifurcation lesions: illustration and comparison with classic crush. J Invasive Cardiol. 2007;19(4):189-193.
8. Colombo A, Bramucci E, Sacca S, et al. Randomized study of the crush technique versus provisional side-branch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) study. Circulation. 2009;119(1):71-78.
9. Mitsudo K. 2005. Data 2005 the 14th PCI live demonstration course in Kurashiki. p. 172.

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From the Department of Cardiology, Sakurakai Takahashi Hospital, Kobe, Hyogo, Japan.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted August 22, 2011, provisional acceptance given October 5, 2011, final version accepted October 19, 2011.
Address for correspondence: Akihiko Takahashi, MD, PhD, Department of Cardiology, Sakurakai Takahashi Hospital, 5-18-1, Oikecho, Suma-ku, Kobe, Hyogo 654-0026, Japan. Email: a-takahashi@wine.ocn.ne.jp