A Novel guide extension assisted stenting technique for coronary bifurcation lesions

Figure 4 Demonstration of the guide extension technique in a complex true bifurcation lesion in the third case. A and B: Left (A) and right (B) coronary angiography. The left anterior descending artery (LAD) system reveals a proximal tri-ostial (medina 1, 1, 1) LAD/diagonal bifurcation stenosis where the LAD is subtotally occluded (thick orange arrows); B: The distal part of the LAD is filled by collateral circulation from the right coronary artery (thick orange arrow); C: The left coronary artery engaged with 7F-XB 3.5 guide catheter. After placing two guidewires, one in the LAD and another in the diagonal artery, and then conventional predilatation of both the main and the side branches, the GuideLiner, mounted on both guidewires, is positioned at the bifurcation carina. A Promus Premier (Boston Scientific, Marlborough, MA, United States) 2.5 mm × 16 mm stent is placed in the diagonal artery; D and E: The stent is retracted so that the proximal stent balloon radio-opaque marker overlaps the radio-opaque marker just proximal to the tip of the GuideLiner (D: Without contrast; E: With contrast; orange arrows); F: The stent was implanted at a pressure of 22 atm; the stent balloon pushes the guide extension catheter backwards; G: StentBoost imaging (Philips Medical Systems, Eindoven, the Netherlands) shows that the proximal stent edge is positioned at the side-branch ostium. After stent implantation in the main branch with a Promus Premier (Boston Scientific, Marlborough, MA, United States) 3.0 mm × 24 mm stent post-dilated with a 3.5 mm high pressure balloon, rewiring of the side branch, sequential balloon dilatation, proximal optimization technique, and final kissing balloon inflation; H: StentBoost imaging reveals a precisely stented bifurcation lesion without unnecessary layers of struts; I and J: Optical coherence tomography confirmed a well-apposed stent and no struts covering the ostium of the diagonal artery (orange arrows); K: Final result (orange arrow). LCA: Left coronary artery; RCA: Right coronary artery.