Provisional Stent with Difficulty
of Side Branch Reaccess
边支再进入困难的“即兴”支架术
LIU Tongku, Ding Fuxiang
The Center of Cardiology, Affiliated Hospital , Beihua University
Jilin 132011, Jilin, China
北华大学附属医院心脏中心
刘同库, 丁福祥
Provisional Stent with Difficulty of Side Branch Reaccess
边支再进入困难的“即兴”支架术
Provisional Stent with Difficulty of Side Branch Reaccess
refers to the phenomenon that is when the bifurcation lesions is treated by
provisional stenting technique, the ostial of side branch is squeezed from lesion
plaques shift to make the side branch ostial stenosis , occlusion or stent beam cover
ostial of side branch, and subsequently to make reaccess difficulty of wire, balloon
or stent.
We report a case of provisional stent with difficulty of side branch reaccess. please
discuss it.
临时支架置入技术(Provisional stenting technique)即“即兴”支架技术
边支再进入困难的“即兴”支架术,是指分叉病变，采用provisional stenting
技术，边支开口受到病变斑块移位挤压，使边支开口高度狭窄或闭塞或支架
挠骨梁覆盖狭窄的边支口，使后续的导丝、球囊或支架再进入困难或不能进
入的现象 ！
我们报告一例边支再进入导丝困难的病例，请指点
Case Presentation(1)
Clinical presentation (Medical record No. 201219041)
A 46 year-old male was admitted due to intermittent chest pain for one year, which
was aggravated in last one week. Indoor walking can induce the chest stuffy pain
before one week. He was admitted to our hospital on 16th November,2012.
When he did heavy physical activity ,typical angina pectoris occurred in nearly 1
year, which can relieve by rest or administering isosorbide dinitrate.
Medical history (previous history)
Before one year he suffered from AMI (inferior wall and posterior wall myocardial
infarction ) to admit other hospital and to do not PCI. After discharged from
hospital he have been taking aspirin, clopidogrel, atorvastatin, and so on, and still
had onset of chest pain.
Risk factor only smoking for 30 years(20 / day).
患者，男，46岁（病例号：201231407）因间断发生劳力性胸痛1年，加重1周，于2012
年11月16日入院。近1年每于重体力活动时发生胸痛呈典型心绞痛发作，休息或含服消
心痛可以缓解。入院前1周症状加重，室内散步可以诱发心绞痛。
既往病史：于1年前患AMI（下后壁）住外院治疗好转，未行介入诊治。出院后口服“阿
司匹林、氯吡格雷、阿托伐他汀”等药物治疗，仍间断有胸痛发作.
吸烟史20年，20支/天。否认高血压、糖尿病病史。
Case Presentation(2)
Physical Examination
T 36.2℃,P 62/min, BP:120/80mmHg（millimeter of mercury).
The heart rate was 60 per minute. Cardiac auscultation showed
that heart sounds was normal, and each valve area was without
murmurs. The tiny bubbles sounds were heard in double lungs
low . His liver was not big and lower limbs no swelling.
T 36.2℃, P 62/min, BP:120/80mmHg
口唇无发绀，无颈静脉怒张，双肺呼吸音清，未闻及干湿罗音。心界叩
诊不大，心率60次/分，心音低钝，节律规整，各瓣膜听诊区未闻及杂音、
额外心音及心包摩擦音。双肺低有少许水泡音。肝脏不大，双下肢无水肿。
The patient’s
electrocardiogr
aph was
abnormal.
R-waves were
lower in Ⅲ and
aVF.
ST segments
and T-waves
were not
abnormal.
The heart rate
was 60 per
minute.
Blood examination
WBC: 3.3×10^9/L
MEUT:50.0%
RBC: 4.31×10^12
HGB: 125g/L
PLT: 172×10^9
Blood Lipid and myocardial enzymes
Chol 3.7 mmol/L
TG 2.8mmol/L
LDL 2.19 mmol/L
HDL 0.77mmol/L
CK-MB 7.06u/L
CK
55.0u/L
a-HBDH 146.0u/L
AST
20u/L
cTnI
0.01ng/L
Glu
4.9mmol/L
Echocardiography
(ultrasonic cardiogram .UCG)
LA
34mm
AO
31mm
LV
45mm
IVS 6.6mm
LVPW 6.6mm
RVOT 26mm
RV
26mm
EF
0.65
Baseline coronary angiogram
Her coronary angiogram was completed on 16th
November, 2012.
Coronary angiogram showed that LCX was CTO lesions
and RCA 3 segment was 90% stenosis ,and without
collateral flow to LCX distal vessel.
CTO lesion
Stenosis lesions
Baseline CAG
Her coronary
angiogram was
completed on
16th November,
2012.
RAO 30°CAG
LCX-CTO
Baseline CAG
CAU 25°
LCX-CTO with
collateral
circulation
Baseline coronary
angiogram
LAO40°
CAG showed
there was stenosis
in RCA 3 segment
CRA 25°
CAG showed
there was
stenosis
in RCA 3
segment
diagnosis
• Coronary heart disease
• Unstable angina pectoris
• Old inferior and posterior wall
myocardial infarction
• Double branch lesions of coronary artery
(LCX-CTO and RCA stenosis)
• Heart function 1 class
Procedure
of PCI（1）
First, A 6 Fr BL
3.5 guiding
catheter was
inserted in ostium
of LM via radial
artery.
We used Whisper
guide wire into
LCX. But Whisper
wire cannot
access the lesion.
Procedure
of PCI（2）
Then we tried to
use a small
balloon (1.5×15
mm) to support the
wire into lesions .
CAG showed the
wire was in true
lumen of blood
vessel .
Procedure
of PCI（3）
We used Whisper
guide wire into
LCX distal and
used small
balloom (1.5×15)
to dilate the
lesions.
Then we inserte
BMW wire into
distal OM3.
we
Procedure
of PCI（4）
We used Whisper
guide wire into
LCX distal and
used small
balloom to dilate
the lesions.
Then we inserte
BMW wire into
distal OM3.
Procedure
of PCI（5）
After the dilatation
with small balloon
CAG showed
bifurcation lesions of
LCX.
We used
provisional stenting.
Procedure
of PCI（6）
We used 2.0×20
mm balloon to
dilate it.
Procedure
of PCI（7）
Stent (Xience V
2.75×18mm)
was inserted into
the LCX lesions
Procedure
of PCI（8）
Stent was
inflated with
14atm×15”
(XIENCE V)
Procedure
of PCI（9）
Post-dilation
with 3.0×12
mm balloon and
with 16atm×15”
Procedure
of PCI（10）
The CAG after the
post-dilatation
showed severe
stenosis of OM 1
ostium
Procedure
of PCI（11）
Difficulty of Side
Branch
Reaccess.
The wire was
operated for
10min.The wire
cannot be
inserted into
OM1, to give up
it.
Procedure
of PCI（12）
Difficulty of Side
Branch
Reaccess.
The CAG after
withdrawn from
wire
Procedure
of PCI（13）
To operate for 10
min, to give up.
This is final result
of LCX
Procedure
of PCI（14）
RCA bifurcation
lesion was
treated with
Culotte stenting
Double BMW wire
were used.
PD ostium lesion
was dilated with
2.0×20mm balloon
12atm×15”.
Procedure
of PCI（15）
In RCA 3-PL
2.75×24mm
partner was
implanted with
14atm × 15”
Procedure
of PCI（16）
In RCA3-PL
3.0×18mm stent
was implanted with
14atm×15”
Procedure
of PCI（17）
This was final
kissing balloon
with 10atm×10”
Procedure
of PCI（18）
The final result
of RCA Culotte
stenting
Discuss
• What is the cause of trouble of side branch
reaccess？
• What is the prevention method of difficulty of
side branch reaccess?
1、Provisional stenting 后，导丝再进入边支困
难的原因?
2、预防导丝再进入边支困难的方法?
Thank you for your attention
报 告 者: 刘同库；E-Mail:liutongku20102163.com; 电话：18943209667
单
位: 北华大学附属医院心脏中心
通信地址：吉林市解放中路12号，北华大学附属医院心脏中心