Modified Sleeve Technique for Calcified Coronary Bifurcations

J INVASIVE CARDIOL 2019;31(3):E52-E53.

Key words: cardiac imaging, new technique, orbital atherectomy

A 72-year-old male with history of coronary artery disease (status post bypass in 1997 with a radial graft to the left anterior descending [LAD]), hypertension, diabetes, hyperlipidemia, deep vein thrombosis, cardiomyopathy (estimated ejection fraction, ~30%), and end-stage renal disease on hemodialysis presented with a non-ST segment elevation myocardial infarction. Subsequent left heart catheterization revealed distal left main (LM) involvement extending to the ostial LAD, ramus, and circumflex (CX) arteries (Figure 1). The CX was 100% occluded. He was referred for surgical evaluation since the internal mammary had not been previously utilized. The surgical team deemed him high risk for surgical revascularization and referred him for high-risk PCI.

Further examination revealed no significant viability in the CX distribution; a two-stent strategy was planned for the LAD and ramus using a double-kiss crush technique. Mechanical circulatory support was inserted given his cardiomyopathy, bifurcation lesion involving the LM, use of orbital atherectomy (OA), and elevated left ventricular end-diastolic pressure. An Impella CP (Abiomed) was inserted via the left femoral artery. An 8 Fr EBU 3.75 guide was inserted from the right femoral approach. We then used a modified sleeve technique to perform OA of the LAD and ramus and maintain wire access. A Runthrough wire (Terumo) was advanced into the LAD and a Samurai wire (Boston Scientific) was advanced into the ramus. We exchanged the LAD wire for a ViperWire (Cardiovascular Systems, Inc) through a FineCross (FC) microcatheter (Terumo). The FC was then advanced into the ramus over the Samurai wire and left in place. OA was then performed from the LM to the LAD. We then reversed the configuration, with the FC in the LAD and the ViperWire in the ramus, and performed OA of the ramus. Following OA, the vessels were predilated with an AngioSculpt balloon (Spectranetics) followed by successful completion of the double-kiss crush technique. The Impella was removed post procedure and the patient was discharged the following day in stable condition.

This is a modification of the previously described GuideLiner sleeve technique. In the same manner, it allows the operator to maintain wire access of both vessels while performing atherectomy. Historically, rotational atherectomy can result in side-branch occlusion in up to 10% of cases. This can potentially result in significant ischemia depending on the territory involved. This modification also avoids the added risk of guide-catheter dissection from two guides in the LM as described in the GuideLiner sleeve technique. This technique can be used in non-LM bifurcations as well. The microcatheter affords wire protection from OA or rotational atherectomy. This technique would not be necessary with laser atherectomy; however, laser atherectomy may not be as effective in heavily calcified lesions. An 8 Fr guide is necessary to accommodate the microcatheter and the 1.25 OA crown or a 1.5 mm Rotaburr. 

From Winter Haven Hospital, Winter Haven, Florida.

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author reports speaker/proctor income from Boston Scientific, Spectranetics, Abiomed, and Terumo.

The author reports that patient consent was provided for publication of the images used herein.

Manuscript accepted October 2, 2018.

Address for correspondence: Zaheed Tai, DO, Winter Haven Hospital, 200 Avenue F NE, Winter Haven, FL 33881. Email: zaheedtai@gmail.com