Small Balloon Inflation Over a Jailed Wire as a Bailout Technique in a Case of Abrupt Side Branch Occlusion (FULL TITLE BELOW)

FULL TITLE: Small Balloon Inflation Over a Jailed Wire as a Bailout Technique in a Case of Abrupt Side Branch Occlusion During Provisional Stenting

ABSTRACT: During provisional stenting of a bifurcation lesion, recrossing into the side branch (SB) can be sometimes difficult or even impossible, especially when the SB lumen is compromised by a dissection. This report describes a rescue technique that can help to restore flow and regain access to the SB lumen in case of total SB occlusion after main vessel stent placement.

J INVASIVE CARDIOL 2010;22:449–452

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The treatment of bifurcation lesions can be technically challenging and is associated with a lower procedural success rate and a higher complication rate compared to nonbifurcated lesions.^1,2 The best approach to manage a bifurcation to achieve optimal procedural outcomes and long-term clinical success is still a matter of debate. To date, randomized studies have failed to demonstrate any clinical benefit of a complex strategy of systematic double stenting using drug-eluting stents (DES) over a simpler strategy of stenting the main vessel (MV) with provisional stenting of the side branch (SB).^3,4 Thus, the provisional stenting approach is the most commonly adopted strategy when treating bifurcation lesions, but can still result in abrupt SB occlusion after MV stent implantation.⁴ In cases of SB compromise, the first step is to pass a guidewire into the SB lumen through the MV stent struts. If this step is successfully achieved, balloon angioplasty and, if necessary, additional stenting of the SB will be performed. However, to obtain an access to the SB with a guidewire can be sometimes challenging or even impossible, especially in the case of a dissection of the SB lumen. Here, we report an original technique that can help to restore flow and regain access to the SB in cases of complete SB occlusion following MV stent implantation.

Case Report

An 87-year-old male with stable angina pectoris and a positive myocardial perfusion scan underwent coronary angiography at our institution. His past medical history includes DES in the mid-left anterior descending artery, hypertension, type 2 diabetes and dyslipidemia. Coronary angiography showed a bifurcation lesion of the left circumflex artery (LCX) involving the mid segment and the first marginal branch, with the main lesion located at the ostium of the marginal branch (according to Medina classification: 0,1,1). The decision was made to use a single-stent strategy in the mid-LCX toward the marginal branch and a provisional wire placed in the distal LCX. A 6 Fr XB 3.5 guiding catheter was used to engage the left main, and 2 Whisper wires (Abbott Vascular, Abbott Park, Illinois) were placed in both the marginal branch and the distal LCX (Figure 1). The lesion of the marginal branch was predilated using a 3 mm diameter SeQuent balloon (B Braun Medical, Melsungen, Germany). A 3.5 x 15 mm Xience stent (Abbott Vascular) was then inserted from the mid-LCX toward the marginal branch and inflated at 12 atm. A control angiogram showed a total occlusion of the distal LCX with thrombolysis in myocardial infarction (TIMI) 0 flow (Figure 2), which manifested clinically by acute chest pain, severe bradycardia and ST-segment elevation in the inferior and lateral electrocardiographic leads. Despite several attempts and the use of numerous wires, we failed to pass into the distal LCX lumen with the last wire (Pilot 50, Abbott Vascular) ending up in a false lumen (Figure 3). As a last resort, the decision was made to inflate a small balloon over the jailed wire in order to restore anterograde flow in the distal LCX, thus potentially helping to ensure correct positioning of a wire into the true lumen of the distal LCX. The use of a 1.25 x 10 mm SeQuent balloon was first attempted, but failed to pass between the stent struts and the LCX vessel wall. Finally, a 1.25 x 10 mm Ryujin plus balloon (Terumo Medical Corp., Japan) was successfully advanced over the jailed wire and was inflated at 16 atm (Figure 4). This allowed immediate restoration of anterograde flow with subsequently diminished chest pain and partial correction of ST-segment abnormalities. Correct visualization of the true lumen facilitated the placement of a wire in the distal LCX through the stents struts. After dilatation of the stent struts toward the distal-LCX with 3 x 20 mm SeQuent balloon (Figure 5), a 3.5 x 38 mm Xience Prime stent was placed in the distal LCX using a modified T-stent and small protrusion (TAP) technique. The procedure was completed by performing a kissing balloon with a good final angiographic result (Figure 6).

Discussion

Placement of a guidewire in the SB is a key step during the provisional approach for the treatment of bifurcation lesions. Once the stent has been placed on the MV, the “jailed wire” on the SB acts as a marker and modifies favorably the angle between MV and SB, decreasing the rate of SB compromise and facilitating the subsequent recrossing of the SB.⁵ Here, a novel use of the jailed wire is reported. In the case of total and symptomatic occlusion of a SB, with failure to pass a guidewire into the SB lumen due to dissection, the inflation of a small balloon over the jailed wire (between the stent struts and the vessel wall) helped to restore flow and to resume opacification of the SB lumen. This allowed regaining the access to the SB which led to a favorable procedural outcome. Several mechanisms can explain SB compromise after MV stent placement and include in particular carina displacement, plaque shifting, ostial dissection, thrombus formation and spasm.⁶ The main predictors of SB compromise are the diameter of the MV stent and the distal angle between MV before bifurcation and SB (angle alpha or carina angle).⁷ Currently, the placement of a protection wire in the SB is the most widely used method for the prevention of SB compromise. Interestingly, Burzotta et al have recently described a technique for SB protection based on the placement of a balloon in the SB during MV stenting. The presence of an uninflated “jailed balloon” has several potential advantages: 1) to minimize carina shifts due to its SB spatial occupation; 2) to act as a marker and a favorable angle modifier to facilitate rewiring; and 3) can be dilated to restore SB flow. This new technique has been used without any complication in 20 patients with true bifurcated lesions (and a “high risk of SB compromise” according to operator’s expertise) undergoing provisional stenting.⁸ SB occlusion after MV stenting occurred in 3 patients. In 2 of these patients, the SB was successfully rewired. In the third patient, SB occlusion caused hemodynamic compromise and the jailed balloon was inflated to restore flow such as in our patient. Although speculative, possible mechanisms explaining SB flow restoration after balloon inflation over a jailed wire include a redisplacement of the carina toward the MV, the creation of a space between the vessel wall and the MV stent struts allowing the passage of blood into the SB and the reopening of the true lumen in the case of an occlusive dissection flap. Although the “jailed-balloon” technique is appealing, it needs to be validated in clinical studies with larger samples before it can be recommended. A major concern with this technique is the possible risk of balloon entrapment in the SB. Accordingly, most operators will still use the classic provisional stenting approach for bifurcation lesions. Therefore, in cases of symptomatic occlusion of a significant SB and the inability to regain access to the SB, one should consider the inflation of a small balloon over the jailed wire toward the SB as a bailout technique. Special care must be taken to use the smallest balloon available to both increase the chance to pass under the stent struts and to avoid major deformation of the stent placed in the MV during inflation. It is also important to consider a 7 Fr, and rarely a 8 Fr system, when dealing with complex bifurcation lesions for better backup and ease in manipulating multiple balloons and stents through the MV stent. If balloon inflation over the jailed wire is not able to restore flow or creates major dissection, the operator can still try the “rescue inverse-crush” technique as described previously.⁹

References

1. Al Suwaidi J, Berger PB, Rihal CS, et al. Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol 2000;35:929–936. 2. Yamashita T, Nishida T, Adamian MG, et al. Bifurcation lesions: Two stents versus one stent-immediate and follow-up results. J Am Coll Cardiol 2000;35:1145–1151. 3. Steigen TK, Maeng M, Wiseth R, et al; for the Nordic PCI Study Group. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation 2006; 114:1955–1961. 4. Colombo A, Bramucci E, Saccà 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;119:71–78. 5. Brunel P, Lefevre T, Darremont O, Louvard Y. Provisional T-stenting and kissing balloon in the treatment of coronary bifurcation lesions: Results of the French multicenter "TULIPE" study. Catheter Cardiovasc Interv 2006;68:67–73. 6. Stankovic G, Darremont O, Ferenc M, et al; European Bifurcation Club. Percutaneous coronary intervention for bifurcation lesions: 2008 consensus document from the fourth meeting of the European Bifurcation Club. EuroIntervention 2009;5:39–49. 7. Vassilev D, Gil R. Clinical verification of a theory for predicting side branch stenosis after main vessel stenting in coronary bifurcation lesions. J Interv Cardiol 2008;21:493–503. 8. Burzotta F, Trani C, Sianos G. Jailed balloon protection: A new technique to avoid acute side-branch occlusion during provisional stenting of bifurcated lesions. Bench test report and first clinical experience. Eurotervention 2010;5:809–813. 9. Furuichi S, Airoldi F, Colombo A. Reverse inverse crush: A way to get out of trouble. Catheter Cardiovasc Interv 2007;70:708–712.

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From the Centre Hospitalier Universitaire de Charleroi, Division of Cardiology, Charleroi, Belgium. The authors report no conflict of interest regarding the content herein. Manuscript submitted May 10, 2010, provisional acceptance given May 25, 2010, final version accepted June 2, 2010. Address for correspondence: Adel Aminian, MD, Centre Hospitalier Universitaire de Charleroi, Bd Paul Janson 92, 6000 Charleroi, Belgium. E-mail: adaminian@hotmail.com