SR

A 59 years old man with underlying diseases of diabetes mellitus, hypertension and dyslipidemia, presented with angina on exertion (CCS angina grade 3) for 3 weeks. He did not  have dyspnea, orthopnea or paroxysmal nocturnal dyspnea. He has current history of smoking (12 pack year). Physical examination revealed BP 150 /90 mmHg, otherwise unremarkable. 

1. Coronary CTA : Total Ca Score 1566.21 HU; LM - moderate stenosis (Ca 232.71 HU) ; LAD - Severe Stenosis, multiple calcific plaque (Ca 220.39 HU); D1/D2 - Moderate stenosis ; LCx - significant stenosis (Ca 13.58 HU); RCA - soft plaque at proximal and mid RCA. 2. Echocardiography: LVEF 86 % , no RWMA ; Diastolic dysfunction grade II, no significant valvular dysfunction

Left main - distal LM stenosis 60 % LAD - Tapering CTO at proximal LAD with collateral from LCx and RCA (JCTO score 2 for calcification and occlusion length > 2 cm) LCx - 70 % Ostial stenosis; 40 % proximal stenosis RCA - 40 % mid stenosis ; 50 % PDA stenosis 
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DK crush is associated with better outcome in management of distal LM true bifurcation lesion however illustrates "no pain, no gain" concept involving multiple steps of wire recrossing. In our case, while stenting the side branch, the main branch wire and balloon to crush the side branch stent was forgotten in the process, and encountered difficulty in rewiring the main branch, however stent enhancement (SE) technology with Crusade microcatheter saved our day and lead to our final success! The utility of stent enhancement (SE) technology in percutaneous coronary intervention for bifurcation lesions can provide valuable information through several stages of procedure like clear visualization of metallic struts and the position of wire in strut opening at the side branch ostium. Stent enhancement algorithm works by identifying the proximal and distal marker of a balloon positioned inside the stent that centers the multiple superimposed frames of a cine loop to create a clear image of the stent. Crusade, a dual lumen micro catheter, has double radiopaque makers that works in perfect combination with stent enhancement technology in DK crush technique treatment of bifurcation lesions. Although the SE technology cannot replace intravascular imaging, the combination with appropriate double lumen catheter, it would definitely minimizing the procedure time and improved outcome of bifurcation lesion stenting. 

























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Our case demonstrates the utility of a perfect combination, stent enhancement technology and dual lumen microcatheter with double radiopaque makers, that can simplify the steps of DK Crush technique in treatment of LM bifurcation lesions.