Bifurcation: a clinical case in acute coronary syndrome.
Coronary bifurcation lesions are considered one of challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis.
There are limited data on the preferred treatment strategy in ST-segment elevation myocardial infarction (STEMI) patients with bifurcation lesions as most dedicated study excluded patients with acute coronary syndrome.
In all comers population a 10-20% of STEMI patients had bifurcation culprit lesion.
In 2018 guideline suggested a provisional approach by stenting the main vessel and implanting a second stent only if necessary as a bailout strategy.
This reccomandation was supported by a large series of study that uniquely documented the superiority of one versus two stent technique.
The same message could also be exported in the context of acute patients, as our clinical case, thanks to registry like COBIS 2 including ST-segment elevation patient.
But this precious advice cannot be applied in all clinical subsets. Expecially when we manage with a relevant side-branch and when the risk of loosing the side branch is very high.
In this subgroup of patient, bifurcation lesion may benefit from a 2 stent approach.
Different technical option are available. Among these, DK-crush and inverted Main Branch stenting across Side Branch (Invertend Culotte or inverted T technique) could be the best choice.
Our patient was a young lady presenting with a lateral STEMI (D1 and aVL).
The culprit lesion was a Medina 1.1.1 bifurcation lesion involving left anterior descending and first-diagonal.
Since our side branch had thrombus inside, the vessel was relevant by definition. Other anatomical characteristique to take into account: relevant size and covering a large myocardial territory.
Planning the strategy to treat our LAD-D1 bifurcation we consider the angle and the difference in size between main and side branch.
We decided to proceed with DK-crush and its recent evolution DK-nano crush.
In conclusion “do it provisional” guideline message is not always possible, 2 stent technique seems to be the best choice in presence of a relevant side-branch / high risk to loose it.
Our take home message is, if the clinical scenario allow it, don’t hesitate to perform a multistep two vessel strategy technique and to try to reconstruct perfect anatomical carina even in STEMI context.