On-Site Intravascular Ultrasound-Guided Stenting for Bifurcation Lesions With Angiographically Difficulty in Separation

A 64-year-old man underwent percutaneous coronary intervention for unstable angina due to mid-left anterior descending artery (LAD) stenosis. Intravascular ultrasound (IVUS) revealed significant differences in LAD vessel diameter across a large diagonal branch (Dg; Figure A). Therefore, we planned ostial stent implantation at the bifurcation of the LAD/Dg. However, accurate stent positioning was challenging due to the difficulty in clearly distinguishing the LAD/Dg bifurcation on available angiograms (Figure B). We then delivered the stent into the LAD, and evaluated its positioning using IVUS images obtained from the ostial Dg to adjust the proximal stent edge (i.e., on-site IVUS-guided stenting method; Figure C). After removing the IVUS catheter from the Dg branch, we performed stent implantation, confirming optimal results on the final IVUS images (Figure D,E).

Figure.

(A) Initial coronary angiogram (CAG) and intravascular ultrasound (IVUS) images at the left anterior descending artery (LAD). IVUS images (i–iii) demonstrate a marked difference in vessel diameter across the bifurcation. CRA, cranial view; Dg, diagonal branch; RAO, right anterior oblique. (B) Challenges arise with stent implantation using the conventional IVUS marking method due to poor angiographic vessel separation. LAO, left anterior oblique; POBA, plain old balloon angioplasty. (C) The CAG shows the “on-site IVUS-guided stenting” technique from the Dg and its corresponding IVUS image. (D) After implantation of the drug-eluting stent. (E) Final CAG and IVUS revealing accurate ostial stenting; (ii)’ indicates the region just before the LAD bifurcation.

Accurate ostial stent implantation can be challenging with the conventional IVUS marking method due to limitations related to vessel overlaps and/or foreshortening, especially in bifurcation lesions. This case demonstrated the utility of the “on-site IVUS-guided stenting” method in guiding accurate stenting when a side branch allows for the insertion of an IVUS catheter. This technique necessitates several procedural precautions: (1) using a larger guiding catheter size (≥7 Fr); (2) delivering the stent into culprit lesions before delivering the IVUS catheter; and (3) carefully removing the IVUS catheter from the side branch under consecutive fluoroscopy prior to stent implantation to prevent stent movement proximally. IVUS images can distinguish stent metal (spherical high echogenic) from stent shaft (linear high echogenic) in common bifurcation models on bench tests (Supplementary Figure). Thus, this novel technique can be effective in achieving accurate stent implantation, even in challenging scenarios involving vessel overlaps and/or foreshortening.

Acknowledgments

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Supplementary Files

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https://doi.org/10.1253/circrep.CR-23-0075