Bifurcation Lesions - Crush Stenting
From Ask Dr Wiki
The Crush Technique:
Ensures complete coverage of the side branch ostium Immediate patency of parent and side branch Excellent immediate angiographic results Restenosis is usually very focal
3 Layers of stent in the main artery Without final kissing balloon inflation high Restenosis rate May be difficult to re-cross side branch Minimal 7Fr guide system required Technical Considerations:
Requires minimum of a 7Fr Guiding system Final Kissing balloon inflation required due to high Restenosis rate
1) Using a minimum 7Fr guide system, both the parent and side branch are wired. Predilation is recommended to ensure optimal balloon expansion and ease stent delivery. It is important to identify which wire is placed in which branch. We recommend either using 2 separate colored guide wires, keeping a marker on 1 wire, or covering a wire with a sterile towel while not in use.
2) Any disease distal to the side branch should optimally be repaired before the final crush step.
3) The 1st stent is advanced into the side branch. This may require further predilitation. Generally, the stent is advanced beyond the delivery point.
4) The 2nd stent is advanced into the parent vessel. This is also placed beyond the intended deployment site.
5) The side branch stent is pulled back into the parent vessel about 5 mm. This ensures adequate coverage of the ostium.
6) The parent stent is pulled back crossing the side branch and the proximal end is placed proximal to the proximal end of the side branch stent.
7) The side branch stent is deployed.
8) Angiography should now be performed to ensure adequate side branch coverage and stent deployment. Distal edge dissections or disease should be addressed before parent stent deployment. Once complete, the side branch wire is removed.
9) The parent stent is deployed.
10) The side-branch is rewired. It is sometimes necessary to change wires to either a hydrophilic wire eg. Whisper, (Guidant, Temecula, California) or Pilot 50 or 150 (Guidant, Temecula, California), or ASAHI Fielder (Abbott Vascular Devices, Redwood City, California), one of increasing stiffness eg. ASAHI Miracle Bros 3 (Abbott Vascular Devices, Redwood City, California), or both eg. Shinobi (Guidant, Temecula, California) or Confienza(Abbott Vascular Devices, Redwood City, California).
11) Kissing balloons are inflated at the bifurcation. It is sometimes necessary to dilate the sidebranch with a small balloon (1.5 mm middle marker balloon) to facilitate a larger balloon for the kiss.
12) Repeat angiography is performed. Wires are removed and final angiography completed.
Despite excellent initial angiographic results, side branch restenosis is still a significant problem with Crush stenting(Up to 25% without kissing ballon inflation). However,most of the restenosis is silent. The above example used Cypher drug eluting stents in the Side branch and Parent vessels. The patient returned with positive stress testing 13 months later. Repeat angiography demonstrated a short segment of significant in-stent restenosis.