Brief Communication
 

Revascularization of Left Main Bifurcation Lesions by
“Mini-Crush Technique” in a subject on Haemodialysis
Shuvanan Ray*, B.P. Chattopadhyaya**, Subhas Kundu***,
P.K.Deb****, Amal Kumar Banerjee$
* Head of the Dept of Interventional Cardiology, A.M.R.I. Hospitals Salt Lake Kolkata.
**Asst. Prof. of Cardiology, N.B. Medical College & Visiting Cardiologist A.M.R.I. Hospitals Salt Lake Kolkata.
*** Registrar A.M.R.I. Hospitals Salt Lake Kolkata.
****Chief Consultant Cardiologist, ESI Hospital, Maniktala.
$Senior Consultant Cardiologist, IPGMER & SSKM Hospital, Kolkata.
Abstract
A 75 old diabetic, hypertensive subject with chronic kidney disease stage V (on haemodialysis) had Acute
Coronary Syndrome. Coronary angiography revealed bifurcation lesion of the distal Left Main Coronary Artery
involving the origins of LAD & LCx, CABG was denied because of comorbidites, old age and unwillingness of
the patient to face the risk of surgery.
The LM bifurcation was treated in “Mini-Crush technique” resulting in TIMI-III flow and there was uneventful
post-interventional recovery without MACE.
Key words : Bifurcation Lesion ; Mini Crush Technique; CABG (Coronary Artery Bypass Graft) LAD (Left
Anterior Descending artery) LCx (Left Circumflex artery ) MACE (Major Adverse Cardiac Events)

INTRODUCTION
Treatment of bifurcation lesions specially when it involves Left main Coronary Artery (LMCA), as a rule is Coronary Artery Bypass Grafting surgery (CABG). But in the elderly subset of patients in presence of long standing Diabetes, Chronic kidney disease (CKD) necessitating haemodialysis the risk of surgery increases manifold. LMCA Disease is not amenable to optimum medical management, patient being denied of the option of CABG and unwillingness of the patient to undergo surgery poses a difficult challenge to the cardiologist with this background revascularization of LMCA bifurcation of our patient is being discussed.
CASE SUMMARY
Mr.Ray, a 75 yr old gentleman was known to be suffering from Type 2 diabetes mellitus for about 25 years. He developed diabetic nephropathy and hypertension. He was on regular haemodialysis for CKD Stage V. For last few months he was having angina on effort. On 17/05/ 08 he developed severe chest pain necessitating hospitalization. ECG revealed anterior wall Non-ST-Elevation Myocardial Infarction; CPK 1550 IU/L CPK-MB 327 IU/L Blood Glucose (F) 158 mg/dl, PP 220 mg /dl, Urea 102 mg/dl, creatinine 6.8
mg/dl. 2D Echo showed anterior wall hypokinesia with Left

ventricular ejection fraction (LVEF) of 40%. Despite medical management it was difficult to control the chest pain and hypotension in the background of pre-existing hypertension. Coronary angiography revealed 95% stenosis of the distal LMCA; there was significant calcification of the Left anterior descending (LAD) & Left Circum Flex (LCx), ostial and proximal one-third of both of LAD & LCx showed 80% stenosis. Right Conary Artery (RCA) showed minor plaques. Patient was referred to cardiac surgeon. Cardiac Surgeon explained the risk of CABG. Patient and relatives were unwilling
to accept surgery and insisted for percutaneous coronary intervention. Risk of Percutaneous Coronary Interventions (PCI), restenosis, contrast induced nephropathy were explained. After written informed consent of the relatives PCI was performed and patient’s haemodynamic status improved and the patient became symptom-free without any Major Adverse Cardiac Events (MACE). Patient was examined at 1 month and 3 month from the date of the PCI. Check Coronary angiography has been suggested at 6 month. Total procedure time was 60 minutes, contrast used 150 ml and fluorotime was 38 minutes.
DISCUSSION
Bifurcation lesions happen to be the most difficult challenge to the interventional cardiologists. The Medina classification describes the lesion subtypes.

Correspondence: Shuvanan Ray,, Head of the Dept of Interventional Cardiology, A.M.R.I. Hospitals Salt Lake Kolkata.
Email : drsubhamanray@yahoo.com
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Indian Heart J. 2009; 61:186-187
 
 
Revascularization of Left Main Bifurcation Lesions
 
Figure 1
Figure 3
 
Zero means no lesion and 1 means presence of lesion. In our
patient status was 1,1,1 as described in the beginning of the
procedure. The higher the values the worse is the challenge.
Treatment of bifurcation lesions can be done successfully by
“Mini Crush Technique” with Drug Eluting Stents (DES).
Even trifurcation lesions can also be successfully treated
with “Mini Crush Technique” 3 Extent of myocardium at risk
supplied by the side branch, the size of the side branch and
severity of disease in the proximal segment of the side branch
all are factors which need to be properly evaluated before
estimating the number and size of the stents.
The risk of trapping of the wire due to the passage of the stent
Figure 2
 
 
Figure 1:shows the pre-interventional status of the LMCA and its branches. As per Medina classification1 the Severity is 1, 1, and 1 (affecting the LCx side branch as well as the left main – LAD continuity – proximal & distal to the carina). The left ostium is hooked with XB3 (Cordis) 7F & lesions were crossed by two stabilizer super soft guide wires (Cordis). After placement of the guide wires in LAD & LCx the bifurcation was treated in “Mini Crush Technique” 2 by putting Supra-limus core (3.5 x 20mm) in the side branch LCx crushing it by a 3.5 x10 mm balloon in the LAD as revealed in Figure 2. Subsequently two Cypher select stents (3 x 28mm & 3.5 x 23mm) were deployed from distal LAD to LMCA at 18 to 20 atmosphere pressure. It was followed by crossing of the wire through the stent – struts into the LCx with the LAD wire, and the failed LCx wire was withdrawn and put into LAD. Side branch (LCx) ostium was dilated with 2.5 x10 mm balloon at 18 atmospheric pressure & LMCA & LAD was post
dilated by 4x10mm balloon at 18 atm. TIMI – III flow was achieved as visualized in Figure 3. Figure 2 . Medina binary classification of coronary bifurcation lesions. (Acknowledgement : European Heart Journal ehm 195 v 1 )
 
 
in the main vessel is also a problem which fortunately did not happen in our case. It was also challenging to cross the struts of the stent to enter the side branch for repeat dilatation of the ostium of LCx.
REFERENCE
1. Thomas M, H. Smith et al: Percutaneous coronary intervention for bifurcation disease. A consensus view from the first meeting of the European Bifurcation Club. Euro intervention 2006; 2: 149 – 153
2. Gallasi A R, Colombo A et al: Long term out come of bifurcation lesions after implantation of drug eluting stents with the “Mini Crush Technique” Catheter Cardiovasc. Interv. 2007
3. Alfredo R Gallasi, Salvatore D et al : The “Mini Crush Technique” for the treatment of trifurcation lesions. Euro intervention Aug, 2008; 4 online publication Euro PCR online. Com.
Indian Heart J. 2009; 61:186-187
 
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