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Clinical Images

King Ghidorah Technique for a Trifurcation Lesion in a Very High-Risk NSTEMI

Kevin Hernández-Flores, MD; Paola Aceves-Chong, MD; Heberto Aquino-Bruno, MD; Roberto Ibarra-Sánchez, MD; Marco Alcántara-Meléndez, MD

June 2024
1557-2501
J INVASIVE CARDIOL 2024;36(6). doi:10.25270/jic/23.00301. Epub February 28, 2024.

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.


A 66-year-old male Jehovah’s Witness arrived at the emergency room having experienced typical persistent angina. Upon arrival, he was hemodynamically unstable. Electrocardiogram showed a high-risk pattern (Figure 1) and hs-cTn of 21 000 ng/L. Coronary angiography showed critical left distal main disease with trifurcation lesion to the left anterior descending artery (LAD), ramus intermedius, and left circumflex artery (LCx) (medina 1-1-1-1), and an 80% lesion in the middle segment of the LAD (Figure 2, 3). After medical consensus with surgeons, we decided to proceed with percutaneous coronary intervention.

 

Figure 1.  Electrocardiogram
Figure 1.  Electrocardiogram with depression and ST elevation (arrow).
Figure 2. Spider view
Figure 2. Spider view of critical trifurcation lesion (arrow).
Figure 3. Antero-posterior caudal view
Figure 3. Antero-posterior caudal view of critical trifurcation lesion (arrow).

 

An 8-French VODA (Boston Scientific) catheter was used through femoral route and 3 Runthrough NS Hypercoat 0.014-inch guidewires (Terumo) were advanced to the LAD, ramus, and the LCx. Intravascular ultrasound (IVUS) OptiCross (Boston Scientific) was performed from the mid-segment LAD to the left main artery; the LAD had severe calcification in the mid-to-proximal segment with a minimum luminal area (MLA) of 3.4 mm2, and the left main artery had severe calcification and an MLA of 3 mm2. (Figure 4).

 

Figure 4. Intravascular ultrasound images
Figure 4. Intravascular ultrasound images (yellow arrows, in calcium).

 

Predilatation was made from the LAD, ramus, and LCx to the left main artery with 3 Ryurei balloons (Terumo) at 8 atm (3.5 x 20 mm, 2.5 x 20 mm, and 2.5 x 15 mm, respectively) (Figure 5). A 3.0 x 32-mm synergy stent was deployed from the middle to the proximal segment of the LAD (Figure 6). Then, 3 stents were advanced and deployed simultaneously from the LAD, ramus, and LCx (Synergy 5.0 x 24 mm [Boston Scientific], Xience Sierra 3.0 x 33 mm [Abbott], and Synergy 3.5 x 16 mm, respectively) (Figure 7). Simultaneous triple-balloon (kissing) inflation at 12 atm was performed with three 2.0 x 15-mm Ryurei balloons (Figure 8); the 3 balloons were simultaneously inflated 3 times.

 

Figure 5. Predilatation of the left anterior descending artery
Figure 5. (A) Predilatation of the left anterior descending artery (arrows in dilation area). (B) Predilatation of ramus intermedius (arrows in dilatation area). (C) Predilatation of the left circumflex artery (arrows in dilatation area).
 
Figure 6. Stent implantation
Figure 6. Stent implantation (arrows in stent location).
Figure 7. Simultaneous stent implantation
Figure 7. Simultaneous stent implantation (arrows).
Figure 8. Simultaneous triple-balloon inflation
Figure 8. Simultaneous triple-balloon inflation (kissing) (arrows).

 

Final IVUS showed adequate expansion and no edge dissections (Figure 9). The final angiographic result is shown in Figure 10. There were no complications at all during the procedure, and the patient was discharged 3 days later.

 

Figure 9.  Intravascular ultrasound.
Figure 9. (A) Intravascular ultrasound to the left circumflex artery (yellow arrows). (B) Intravascular ultrasound to left anterior descending artery (yellow arrows). (C) Intravascular ultrasound to ramus (yellow arrows).
Figure 10. Final result
Figure 10. Final result (arrows).

 

Affiliations and Disclosures

From the Department of Interventional Cardiology, Centro Médico Nacional 20 de Noviembre, ISSSTE, Ciudad de México, México.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Kevin Hernández-Flores, MD, Department of Interventional Cardiology, Av. Félix Cuevas #540, Col. Del Valle Del. Benito Juárez, C.P. 03100, México. Email: kevinrene9191@gmail.com

 


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