“SKS is not dead” - A Case Report Of Dual Stenting Technique in the Management of a Complex Coronary Bifurcation Lesion During ST Elevation Myocardial Infarction
Article Category: Case Presentation
Published Online: Jun 30, 2024
Page range: 102 - 105
DOI: https://doi.org/10.2478/rjc-2024-0013
Keywords
© 2024 Risca Sever et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
The management of complex coronary bifurcation lesions during an ST segment elevation myocardial infarction represents a significant challenge for interventional cardiologists. The choice of stenting technique is crucial, and it should aim to restore optimal coronary perfusion, reduce procedural complications, and improve clinical outcomes. This case report discusses the use of simultaneous kissing stents in a patient with a thrombotic occlusion in the RCA and associated stenosis in the mid-LAD during STEMI.
A 53-year-old male patient with a history of arterial hypertension and type 2 diabetes presented to our emergency department within 7 hours of severe chest pain onset. The patient was hemodynamically stable, with an unremarkable clinical examination. His presenting electrocardiogram (ECG) showed ST elevation in inferior and posterior leads (Figure 1).
Figure 1
Presenting electrocardiogram: ST elevation in D2,D3, aVF and ST depression in V1-V2, D1,aVL.
Given the presentation of ST elevation myocardial infarction (STEMI), the patient was urgently taken to the catheterisation lab. Right femoral artery access was obtained, and coronary angiography revealed a thrombotic occlusion in the second segment of the right coronary artery (RCA), along with a 50% stenosis in the mid-left anterior descending artery (LAD).
After identifying the thrombotic occlusion in the RCA, wire crossing was successfully achieved using a workhorse guide wire. Upon advancing the wire, a thrombotic lesion was observed at the level of the crux cordis, Medina type 1,1,1. Balloon dilatation prior to stent implantation was avoided due to the large thrombotic material. At this time during the procedure, the patient developed signs of hemodynamic instability. A simultaneous kissing stents (SKS) technique was employed. Two drug-eluting stents, 3.5/12 mm and 3.0/12 mm, were simultaneously inflated in the distal RCA to the posterior descending artery and the retro posterior branch, respectively (Figure 2). Post-procedure angiography confirmed excellent result with Thrombolysis in Myocardial Infarction (TIMI) 3 flow (Figure 2).
Figure 2
A. Second segment of the right coronary artery occluded by thrombus. B. Bifurcation lesion of the crux cordis after workhorse guide wire crossing. C. Simultaneous kissing stents of the retroposterior branch and posterior descending artery. D. Balloon inflation of the 2 stents. E. Final result showing good peripheral perfusion..
The patient experienced immediate relief from chest pain after the procedure. Subsequent ECG showed resolution of ST-segment elevation, and his cardiac ultrasound revealed inferior wall motion abnormalities with a mildly reduced left ventricular ejection fraction of 45% with no significant valvular disease. Cardiac biomarkers demonstrated significant myocardial injury (initial high sensitivity troponin 5316 pg/ml, creatine kinase 1771 mg/dl, and creatine kinase -MB 151 mg/dl) with complete resolution within 72 hours.
The patient’s hospital course was uneventful, and he was discharged on dual anti platelet therapy, statin, beta-blocker, and angiotensin-converting enzyme inhibitor. He was advised to participate in cardiac rehabilitation and follow up with his cardiologist regularly.
At 6-month follow-up, his ECG showed normal sinus rhythm, his cardiac ultrasound revealed mild hypokinesia of the apical inferior wall with 50% left ventricular ejection fraction, and coronary angiography, using optical coherence tomography (OCT), revealed an optimal result of the stented bifurcation of the distal RCA and demonstrated functional neo carina with no malapposition and successful endothelialization of two stents (Figure 3).
Figure 3
Optical coherence tomography (OCT) demonstrated functional neo carina with no malapposition and successful endothelialization of two stents.
Cardiac interventions in the setting of a ST-elevation myocardial infarction (STEMI) often require complex decision-making, especially when confronted with coronary bifurcation lesions. Four common strategies for treating such lesions are provisional stenting, simultaneous kissing stents, double kissing crush, and the Culotte technique. Each approach should be chosen based on patient-specific factors and lesion characteristics. We discuss the rationale behind this choice, the procedural details, and the patient’s clinical outcomes. [1]
Provisional stenting, widely used, is a simpler technique that is less time consuming and minimizes the use of stents and subsequently the risk of restenosis. It allows for the assessment of side branch stenting based on post-dilatation results. [2] However, this method may not provide immediate revascularization of the side branch, and there may be a need for additional procedures should the side branch be compromised during main vessel stenting. [3][4] The SKS technique has the advantage of immediate revascularization of both the main vessel and the side branch. It is well-suited for cases with significant stenosis and/or occlusion in both branches, but the side branch may be distorted or crushed during deployment. Therefore, appropriate stent sizing and positioning is necessary in order to avoid malapposition and restenosis. [2] The direct kissing crush technique addresses both branches in a staged manner, thus allowing for precise placement of the stents in each branch. It may be suitable when provisional stenting alone is insufficient. Potential downfalls include the requirement of multiple steps, which increase procedure duration and contrast exposure. There is a risk of stent distortion, crushing, and malapposition during the crush step. The main limitation of this procedure is the risk of incomplete revascularization if any step is unsuccessful. [3] The Culotte technique offers the advantage of a two-stent strategy with good side branch access. It is effective if used in addressing complex lesions with significant involvement of both (usually) equally sized branches and can achieve good stent apposition and coverage. This technique is more complex, with a risk of stent deformation, crushing, and malapposition during deployment. [5]
In the situation of a STEMI patient with a coronary bifurcation lesion, the choice of strategy should be guided not only by lesion complexity, but also anatomy, operator expertise, and the patient’s overall clinical status. SKS may provide immediate revascularization of both branches in complex lesions. Ultimately, the decision should be made on a case-by-case basis, considering the trade-offs between the procedural complexity and immediate revascularization. [6][7]
In this case, the dual stenting technique using simultaneous kissing stents proved to be an appropriate and effective approach for the management of a complex coronary bifurcation lesion during STEMI. The choice of stenting technique should always be tailored to the individual patient’s anatomy and lesion characteristics, with the goal of optimizing coronary perfusion and minimizing complications.