Bifurcation Lesion of a Y-shaped Saphenous Vein Graft Treated Via Mini-Crush Technique

Abstract

A 77-year-old female patient presented in ER with progressing ischemic chest pain for last 3 days. Electrocardiogram (ECG) was sinus rhythm with minimal ST-depression in leads D1, aVL, V5 and V6. Patient had diabetes, hypertension, hyperlipidemia and coronary artery bypass graft surgery that performed 10 years ago. Her first cardiac troponin level was 68 ng/L at admission later (cut-off 0.01-0.04). D-dimer and creatinine levels were 
normal. Saturation was 94% in room air at pulse oximetry and blood pressure was 140/80 mmHg. Bedside echocardiography revealed an ejection fraction of 45-50% with septal and lateral wall hypokinesia, and 1-2 mitral valve regurgitation. Patient admitted in coronary intensive care unit with the diagnosis of myocardial infarction with non-ST elevation. After treatment with 5000 IU intravenous unfractionated heparin and 300 mgr acetylsalicylic acid, the patient was transferred to the catheterization laboratory. Coronary angiography was performed via the right femoral artery and revealed a total occlusion of the native left anterior descending, 
right coronary artery and Optus margin1 (OM1). Additionally, patent LIMA to LAD bypass and critical bifurcation stenosis in the Y-graft to the diagonal-1 and OM1 arteries was observed (Figure 1). The decision was made to treat the lesion of the venous graft as treat in the native coronary arteries. Given the degree of atherosclerosis involving both branches of the Y-shaped venous graft, a stenting technique fully covering the bifurcation segment of the graft was considered, the “mini-crush” technique with the 
use of paclitaxel-eluting stents, was selected. Before beginning the procedure, intracoronary clonitap (10 mgr) and ticagrelor 180 mgr. p.o was applied and the lesions was wired with a floppy (workhorse) guidewire (Asahi Intecc Medical); and the venous graft branch supplying the D1 was considered as the main branch. Following the steps of the “mini-crush” technique as described before, a 3.0 × 20 mm paclitaxel-eluting stent was used for the side branch while a 3.5 × 24 mm stent was used for the main branch (Figure 2). After the final POT the procedure was completed with a TIMI 3 flow pattern in both branches (Figure 3). Generally, the use of embolic protection devices were suggested for interventions performed in SVG; however, this option was not available in our catheterization laboratory when the procedure was performed.