Double-V Side-Branch Stenting Followed by Main Trunk Stenting in Type-A3 Trifurcation Coronary Artery Disease Using a Dual-Catheter Technique — The Triple-Tine Fork Technique

ABSTRACT: We report on a 55-year-old male patient who presented with acute non-ST elevation inferolateral myocardial infarction. He underwent conventional coronary angiography 3 days after admission that revealed normal right coronary artery, 30% plaque in mid-left anterior descending artery as well as total proximal left circumflex artery occlusion, which proved to be a type-A3 trifurcation lesion after predilatation. The trifurcation was approached with triple wiring and tackled with a novel 4-stent strategy that predicates at first the distal two side branches and the distal main branch (MB) stenting using dual 6 and 7 Fr guiding catheters that were introduced via a bifemoral approach, followed by main trunk (proximal main vessel) stenting with final trissing-balloon inflation. Angiography at the end of the procedure revealed a triple-tine fork-like shape. There was no postprocedural pain or CPK leakage. One year later, the patient was free from any cardiac complaints.

J INVASIVE CARDIOL 2013;25(10):E198-E202

Key words: double side-branch stenting, dual-catheter technique, triple-tine fork technique, type-A3 trifurcation disease

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Trifurcation percutaneous coronary interventions (PCIs) remain an off-label indication for percutaneous revascularization in recent guidelines. There are few data about them, and no standardized techniques. Trifurcation PCIs are reported to have higher overall target lesion revascularization than bifurcation PCIs,^1,2 and may require the use of various complex interventional techniques as well as many bail-out procedures and possible use of intra-aortic balloon pump.¹

At operator discretion, this procedure may dictate the implantation of 1, 2, 3, or 4 stents, and may or may not include final kissing-balloon inflation (FKBI), or better called “final trissing-balloon inflation.”^1,3 

The restenosis rate of lesions treated with a systematic triple-stenting approach can reach up to 40%-75%.^1,4 Intravascular ultrasound (IVUS) use was limited and performed mainly in the main branch.⁴

Several specially designed trifurcation techniques have been used to tackle trifurcation coronary lesions.^1,4,5,6 Our aim is to propose and describe a novel trifurcation stenting technique using a 4-stent approach performed in Shammas type-A3 non-left main (LM) trifurcation lesion, and to compare it with the most currently used techniques.

Procedure Description. For the purpose of clarification, we adopted the nomenclature proposed by Shammas et al for naming the trifurcation branches: main trunk (MT) for proximal main vessel, main branch (MB) for distal main vessel, first side branch (SB1), and second side branch (SB2).⁶ In this case, we propose a novel technique by which we predilate and then stent the two SBs as well as the MB of the coronary trifurcation at first (starting distal in the bifurcation). A 9 Fr sheath or, alternatively, both a 6 and 7 Fr sheath accessed via a bifemoral approach are needed to make the simultaneous advancement of 3 stents possible. The proximal markers of the 3 stents are positioned together with a slight protrusion in the MT in order to create the two proximal carinae. One should deploy the two SB stents sequentially before the MB stent to guarantee sufficient flaring to the proximal edges of the SB stents just above the plane of the MB proximal struts. The most demanding step in this technique is approximating the MT stent along the middle MT-MB wire. Careful advancement of the MT stent distally should be performed to allow overlap with the lateral protruding struts of the SB stents, but not capturing within the proximal MB struts. Meanwhile, one should keep the peripheral SB wires until just before MT stent deployment to help in MT stent centralization. Finally, wire recrossing toward the first and second SBs is done to perform the final trissing balloon inflation with non-compliant balloons at high pressure to help re-form the two carinae. The poststenting angiographic result would resemble a triple-tine fork-like frame. This technique constitutes, in fact, the reverse of the double-modified V- or SKS-stenting,⁷ a double V-stenting with skirt, or a trousers and seat technique,8 but with an extra limb. To our knowledge, this is the first time such a technique has been described in the literature.

Case Report. The patient was a 55-year-old male with the following risk factors for coronary artery disease: hypertension, hyperlipidemia, and smoking. He presented with acute non-ST elevation myocardial infarction. He remained stable after admission. Angiography was performed on the day 3 of admission and revealed normal right coronary artery and a 30% plaque in his mid-left anterior descending artery. He had total proximal trifurcation left circumflex coronary artery occlusion (Figure 1). 

The patient was premedicated with aspirin and clopidogrel, and was upfronted with tirofiban since admission. Bolus injection of unfractionated heparin 7000 U was also given before the procedure. Through bifemoral approach, both 6 and 7 Fr guiding catheters (GCs) were introduced. The total left circumflex coronary artery occlusion was crossed with two polymeric guidewires that were advanced via the 7 Fr GC in the MB and SB1 (Figure 2). After kissing-balloon predilatation (Figure 3), a third wire was advanced via the 6 Fr GC that succeeded in crossing the SB2 (Figure 2). Next, 3 appropriately sized stents (1:1 stent-to-artery ratio) were positioned in the MB, SB1, and SB2 (2.75 x 15, 2.5 x 15, and 2.5 x 15 drug-eluting stents, respectively (Figure 4). The SB1 and SB2 stents were deployed sequentially at 10 to 12 atm and then at 10 to 12 atm simultaneously. Next, the MB stent was deployed to guarantee sufficient flaring to the proximal edges of the SB stents just above the plane of the MB proximal struts. Simultaneous inflation of the 3 stents was then performed with 3 non-compliant balloons, at sufficient pressures to obtain adequate expansion of the 3 stents (Figure 5). Subsequently, the MT stent was advanced distally along the middle MT-MB wire to a degree sufficient to allow overlap with the lateral protruding struts of the SB stents (Figure 6). The peripheral SB wires were left in situ until just before MT stent deployment to help in MT stent centralization. Finally, wire recrossing toward the first and second SBs was done to perform the final trissing-balloon inflation using 2.5 x 12, 2.5 x 12, 2.75 x 12 NC balloons at 16 atm (Figure 7). Care was taken to keep the proximal markers of the 3 balloons well inside the MT stent. The final post-stenting angiographic result was excellent (Figure 8). IVUS was not performed. Closure of the 6 Fr arterial puncture was performed using an Exoseal closure device (Cordis Corporation) while the 7 Fr arterial puncture was closed using manual compression. The patient had an uncomplicated 2-night stay in-hospital and was discharged after that on dual-antiplatelet therapy. There was no postprocedural chest pain, electrocardiographic changes, or CPK leakage. One-year postprocedural course was also free of events. The patient declined routine follow-up angiography at 1 year since he was totally asymptomatic.

Discussion. A bifemoral approach was undertaken to allow for a dual-GC technique. Both 6 and 7 Fr GCs were used to facilitate simultaneous delivery of 3 stents. By using 2 smaller GCs instead of a single larger GC (9 Fr), this technique permits the performance of a complex procedure with many potential advantages, including fewer peripheral vascular complications, less amount of contrast medium use, less GC-tip induced coronary artery ostial trauma, and easier GC manipulation. In fact, the dual-catheter technique is safe and usually poses no major additional technical challenges, although it entails obtaining a second arterial access, which may carry an increased risk of vascular-access complications. These caveats may be effectively lessened by choosing the transradial approach for the second or even both vascular accesses. Furthermore, the potential unusual complications, such as LM dissection and hypotension, may be avoided by engaging 1 GC at a time while retracting the other, as well as by using a GC with side holes.⁹

All 2-stent and 3-stent bifurcation techniques can be used for trifurcations;^10-16 however, herein, they are performed in double- or plus-balloon versions. Three or 4-stent strategies as intention to treat provide superior acute angiographic results and may be recommended in case of trifurcations with large SBs and those with difficult take-offs when a significant plaque shift is expected. A double-modified SKS approach may be performed; this strategy has been recently tested by Isaaz et al⁷ in its single version in bifurcations and was found to ensure optimal stent apposition with high immediate procedural success and low rates of long-term events. However, this approach entails protective normal proximal MT stenting before SB stenting to avoid antegrade SB dissection, which may hamper wire crossing in SBs at later steps. Rewiring is not needed in this approach; however, advancing 3 SB stents via the MT stent may prove to be difficult in many situations due to friction or angulations (Figure 9 and Table 1). 

On the other hand, double-crush or mini-crush techniques are feasible options described in many cohort studies in left main and non-left main trifurcations^1,4 and may require just one 7 Fr sheath when performed in a step fashion. However, double crushing poses several difficulties, including difficult rewiring after MT-MB stenting, since the SB wires are lost very early by intention. In addition, there is great potential to have difficulty in approximation of the MT-MB stent due to a number of accidentally protruding inner SB struts deployed beforehand and inadequately flattened. Final trissing-balloon inflation is usually not possible in double mini-crush stenting since the MT size, by selection, is not large enough to accommodate such inflation (Figure 9, Table 1). 

Alternatively, we propose herein a new technique by which we first stent the distal trifurcation (the SBs and the MB), and then the proximal one as a second step. In this technique, wiring is relatively simple, and stenting the SBs and the MB vessel is also not difficult since it is done systematically before MT stenting, despite the fact that it needs a 9 Fr catheter or dual-catheter placement to be accomplished. Inherent to V- and Y-stenting, there will always be a small bare area between the plane of the upper struts of SB stents or the lower MT stent and the circumferential entry planes of SB stents, which will be confined by the overall final 3-dimensional stent framework. The same thing applies to the method described here, since it is essentially a double-V technique. The aim in this case would be to minimize this small, externally covered area of non-overlap to as minimal as possible; this is done by pushing the MT stent to a degree sufficient to allow overlap with the lateral protruding struts of the SB stents, but not capturing within the proximal MB struts. In our novel technique, the presence of a wire in the MT-MB axis tends to facilitate MT stent approximation, whereas in the Y-stenting bifurcation technique, remounting of the MT stent over 2 balloons would be essential to effect the same result.¹⁶ In general, the triple-tine fork technique offers simpler trifurcation SB wiring, re-wiring, and MT stenting without the need to stent a normal proximal MT first (as in double-modified SKS) or to re-cross layers of stents (as in double-crush techniques). 

On the other hand, single main-vessel (MT-MB) stenting as a stand-alone strategy (keep it open) and provisional strategies such as single main-vessel stenting with provisional SB1 and SB2 stenting as well as 2-stent SKS strategy to MT-MB/MT-SB1 with provisional SB2 stenting, can be used to treat trifurcation coronary artery disease, especially with SB size <2.25 mm, SB supplying a small area of myocardium, or SB unsuitable for stenting (Table 2). However, these techniques usually yield inferior acute angiographic results and are not advised when the SBs have problematic take-offs. While the provisional strategy is the easier approach for the treatment of the majority of trifurcations, an appropriate decision to strongly consider a 3-stent/4-stent approach as intention-to-treat at the outset will save time and money and reduce the risk of complications, especially when the operator or the clinical status of the patient does not accept a suboptimal result in the SBs.

Recently, the strategy of elective 2-stent strategy with the crush technique was not found to provide better outcomes than the strategy of provisional stenting.^17,18 Meanwhile, the conservative strategy for provisional SB intervention was found to be associated with results comparable to a more aggressive approach.¹⁹ These findings, when added to the easier steps these provisional strategies entail, would favor preserving the 3-stent/4-stent strategies for the most demanding trifurcations. To date, however, it is uncertain how these approaches compare with one another regarding in-hospital and long-term outcomes.

Conclusion. Double-modified V-stenting of the side branches followed by MT skirt, using a dual-catheter technique, is a feasible option in type-A3 trifurcation disease. It offers several advantages when compared with double-crush/mini-crush, double-modified SKS, single-MV stenting, and single MV stenting with provisional SB stenting.

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From the Adult Cardiology Department — Queen Alia Heart Institute, King Hussein Medical Center, Royal Jordanian Medical Services, Amman, Jordan.

Disclosure: The authors have completed and returned the ICMJE Form for Dis- closure of Potential Conflicts of Interest. The authors report no conflicts of interest re- garding the content herein.

Manuscript submitted March 26, 2013, provisional acceptance given May 20, 2013, final version accepted June 10, 2013.

Address for correspondence: Abdallah Fandi Yousef Omeish, MD, FACC, FRCP, Senior Consultant Invasive Cardiologist, PO Box 2251, Amman - Jordan 11821. Email: Abdallah.omeish@yahoo.com