Kissing Balloon Angioplasty of a Ci...

Kissing Balloon Angioplasty of a Circumflex Artery Bifurcation Lesion (*1)

In the initial years of coronary angioplasty, coronary artery bifurcation lesions constitued a specific contraindiation because of the risk of occlusion of side branches after single balloon inflation. [1] Because of increased experience and improved balloon technology, these difficult anatomic situations can be treated nowadays using several approaches. In the "kissing balloon" technique, brace guiding catheters are positioned in the sinus of Valsalva and alternatively in the coronary ostium. A guidewire and balloon catheter are introduced into each of the bifurcation ducts The two balloons can be inflated simultaneously or sequentially. This technique requires pair guiding catheters through two separate arterial perforates [2] Another technique is the use of individual guiding catheter, one dilatation balloon, and common protective exchange wire. [3] A modification of this single in kind guiding technique was described on Serruys et al; [4] they utilized brace exchange wires, one in the left descending artery and individual in a large septal branch. the two stenoses were sequentially dilated.

In this report an alternative approach utilizing a single guiding catheter and brace balloons is described. This special technique has become possible by means of the use of a recent ultra-low-profile coronary angioplasty device, introduced by the agency of USCI: the balloon-on-wire probe. In a preliminary report, Myler et al [5] discussed this device and its use in coronary artery disease.

CASE REPORT

A 48-year-old man with previously stable angina pectoris unfolded increased frequency and duration of chest pain resistant to treatment with metoprolol. A standard 12-lead electrocardiogram showed ST-segment depression of 005 mV in leads 2 3 aVF, [Vsub5] and [Vsub6] An exercise standard performed in January 1988 during beta-blockade, was stopped at 110 W and at a heart rate of 110/min because of complaints of angina accompanied from depression of the ST-segments of 03 mV in leads [Vsub4-6] Cardiac catheterization was performed shortyly after. The left ventriculogram showed hypokinesia of the inferoposterior portion and normal contraction of the remaining part of the left ventricle. The coronary arteriogram showed a 90 percent left circumflex artery diameter stenosis in the AV-sulcus branch of this artery, and a 70 percent stenosis at the origin of a large obtuse marginal branch (Fig 1) Posterolateral branches of the left circumflex artery were opacified on collaterals during right coronary arteriography. It was decided to perform PTCA of the couple lesions according to the kissing balloon technique, on the other hand using one guiding catheter and sum of two units balloon-on-wire probes.

After introduction of a temporary pacing catheter via the right femoral vein, a 9F extended sheath was introduced into the right femoral artery using the Seldinger technique. Heparin (10000 U) was administered intravenously and 10 mg nifedipine sublingually. A 9F left Judkins guiding catheter (Cordis) with a three-valve adaptor onward its proximal end, was advanced into the ostium of the left main coronary artery. After adequate shaping of the tip of the wire, a 25 mm steerable balloon-on-wire probe (USCI) was advanced across the AV-sulcus branch stenosis, considered to be the mostly severe one. A inferior 3.0 mm balloon-on-wire probe was introduced by the and of the same guiding catheter and advanced across the obtuse marginal branch stenosis. Balloon inflations were performed simultaneously during 45 next to the firsts with a maximum inflation squeezing of 6 atmospheres (Fig 2) extremely good imaging of the coronary arteries was obtained with the deflated balloons still positioned in the dilated stenoses. Run-off of contrast agent yet the AV-sulcus artery was clearly improved (Fig 3) Subsequently the two balloon probes were removed and repeat-angiograms were performed (Fig 4) The guiding catheter was remov and the arterial sheath after six hours according to local routine.

The post-procedure course was uncomplicated and directly eight weeks after the PTCA, he is delivered of angina and has performed a ascendency exercise test without complaints or ST-segment abnormalities, reaching a maximal heart rate of 180 beats through minute and stopping exercise because of exhaustion at 150 W

DISCUSSION

The original technique for simultaneous balloon inflation to dilate bifurcation lesions in the coronary arterial tree was called "kissing balloon" angioplasty. [26] immediately the most common method of double balloon coronary angioplasty is sequential dilatation of the major duct and thereafter the side branch. [7] If the side branch is large and its proximal part is relatively unrestrained of stenosis, only an exchange wire in the side branch may be sufficient because risk of occlusion of this branch is acceptably gentle in these cases. If side branch occlusion after PTCA of the main branch befalls a dilatation catheter can be advanced through the whole extent of the exchange wire and positioned into the side branch to re-open this tube these techniques have in belonging to all the use of two arterial guiding catheters.