Salvage of side branch by provisional "TAP technique" using Absorb™ bioresorbable vascular scaffolds for bifurcation lesions: first case reports with technical considerations.
Bottom Line: We report for the first time, the successful use of the "T and Protrusion" (TAP) technique of deploying BVS into the side branch (SB) through the struts of main branch (MB) BVS to salvage a suboptimal result and threatened closure of a SB in three cases when treating bifurcation lesions with a planned single BVS strategy.The TAP technique was successful in all cases and there were no complications.All patients continue to do well at short-term follow-up.
Affiliation: Department of Interventional Cardiology, Fortis Escorts Heart Institute, New Delhi, India.Show MeSH
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Mentions: A 62-year-old diabetic and hypertensive female suffered a non ST elevation anterior myocardial infarction 4 days prior to admission. Angiography demonstrated bifurcation lesion visually estimated 80% stenosis of the left anterior descending (LAD) artery and 1st diagonal (D1) branch (Medina classification 0, 0, 1). The LAD was 3 mm in diameter and D1 was 2.5 mm in diameter (Fig. 1a). Both LAD and D1 were wired with floppy wires (Balance Middle weight Universal (BMW), Abbott Vascular, Santa Clara, USA). The LAD was predilated with 2.75 mm × 15 mm non-compliant (NC) balloon at 18 atm. D1 ostium was predilated with 2.0 mm × 12 mm NC balloon at 12 atm. LAD was then stented with 3.0 mm × 28 mm BVS at 10 atm and post dilated with 3.0 mm × 15 mm NC balloon at 22 atm. Following this, the D1 ostium was noted to be 90% stenosed (narrowed) with dissection (Fig. 1b). The struts of the MB BVS were crossed with a BMW wire (Abbott Vascular, Santa Clara, USA) into the D1. The D1 ostium was crossed through the struts of MB BVS and dilated sequentially using a 2.0 mm × 10 mm and 2.5 mm × 12 mm balloon up to 14 atm (Fig. 1c). The D1 ostium still revealed a significant residual stenosis with recoil and dissection. To salvage this, a 2.5 mm × 18 mm BVS was passed over the D1 wire through the struts of MB BVS into the D1. The proximal balloon marker of the SB BVS was placed just proximal to the SB ostium, such that the proximal scaffold marker was at the ostium and it was deployed at 10 atm (Fig. 1d). Further post-dilation of SB BVS was performed using 2.5 mm × 12 mm NC balloon to 20 atm followed by dilatation of MB BVS with a 3.0 mm × 12 mm NC balloon to 20 atm. Simultaneous snuggle balloon dilatation (as described in the discussion) was performed for final optimization of result. OCT imaging was performed in the MB as well as SB and showed good coverage and optimization of scaffold geometry at the bifurcation with no disruptions (Fig. 2). The patient was discharged uneventfully after 2 days and continues to do well at 10-months of clinical follow-up.
Affiliation: Department of Interventional Cardiology, Fortis Escorts Heart Institute, New Delhi, India.