<v Dr. Chen>Thank you very much for inviting me</v> to present a double kissing crush technique. I will introduce my case step by step. So patient is 74 years old. He have a multiple risk factors, previous smoker, hypertension, renal failure, unstable angina for three months, left ventricular ejection fraction was 46%. So, this baseline angiography. So, from left to right are AP caudal, RAO cranial, spider view. So all the video shows very diffuse edema and some plaques. So we use the six French guiding catheter from trans femoral artery. So from AP caudal, you can see very tight lesion as it cross the single plaques, and also a very tightened stenosis at the proximal LAD. So from the videos, we can calculate the possible diameter of left main to be around 4.5 to 5 millimeter. So immediately after predilation for distal symplastic lesion, we check the IVUS. So from two still image of IVUS, as you can see, it has a middle body of left main. There is a very, very large lipid pool which indicates it's a unstable plaque in the left main. I'm also from some flares to left main has a constitutional flare. You can see a very critical stenosis, also very long crown lens. So we go through DK crush through BMW wire instant flares in LAD. So from the spider view, we can be precisely calculate the lesion as. So finally, we use a long stent instant flares. It's 3.0 x 28 millimeter SES DS and as we fire balloon in LAD, so keep the air in the balloon in the position is very important because immediately after stenting instant flares, we needed to flush the balloon crush. So on the right figure, you can see the stent instant flares or the (indistinct). But the middle segment of some flare, stent was not inflating perfectly. So immediately after stenting some flares keep the balloon in LAD. So, I was to check the stent inflation quality. These three imaging came from Dr. Francesco Lavara, my good friend. He modified the piece there for optimizing inside the stent. So it means if there is any one side branch taken from the proximal stent flares. So the stent, side branch stent size should be undersized for the very proximal stent flares. So this is why we need to do one more optimizing side branches stent using another non-compliant balloon. So according to the study I was studying, so you can see after optimizing inside the stent, so the ostia of the side branch, the stent expanded very, very good. So after stenting stent flares you usually keep the wire inside the branch and you see another 3.5 x 12 non-compliant balloon to do for the kissing balloon inflation. So what should be kept in mind is that the balloon size is the underside for left main. So here, I show that I was fighting immediately after the first balloon crush, you can see the gap between two layers of (indistinct) is pretty large. So it means that we need to do further balloon crush using a 4.0 x 12 non-compliant balloon to completely crush the side stent. As I showed in this video, immediately after the balloon crush, you need to rewires the side branch. 'cause, you know, we kept the jailed... we kept the third wire in the position. So, we use the third wire according to the map of the previous wire in stent flares to rewire from the proximal cell. So this is very important because the stent flare has been crushed much more. So actually the proximal cell is pretty small and irregular. So we can rewire from the proximal to middle cell. But the key point is that in order to rewire from the distal cell because the balloon crush there is a gap between side of stent with the carina. So immediately after successful rewire into stent flare, we need to do first the kissing balloon inflation. So the leftover is a right kissing balloon inflation only to right through figures I provide how ugly of the kissing inflation. So in general, the kissing triple balloon should be overlapping as short as possible in the left main to recreate the middle carina. So after kissing balloon inflation, we use the long stent from LAD to fully cover the ostium of left main. Immediately after stenting LAD to left main, we use the full non-compliant balloon to post dilate this easily, second in part to make sure the full expansion of the left main stent. So after second part, we needed to rewire some flares again. Personally, I approved for the use of BMW wire to rewire stent flares. And also from the left AP caudal image, we can clearly say if they (indistinct) the wire access to some flares from the proximal or middle cell. Once it is successfully into stent flares, we need to do second kissing balloon inflation. So for kissing balloon inflation, usually we recommend two sequential inflation study from side of branch. So usually we need to inflate these other branch with balloon by minimal 16 atmospheres. After that, we need to do some alternative kissing inflation with very short overlapping of post stent in the left main. For this case, we use the 3.0 instant flash and now is 3.5 in LAD. So after final kissing inflation, so final part was performed successfully. This final angiography, from AP caudal, RAO cranial, and also from spider view. After kissing, (indistinct) for this case, we made sure the invasive FFR for tissues and flares, it was greater than 0.80. So we did not touch the distribution in stenting at all. So, finally, we recheck the IVUS study from LAD to left main on the left side and from stent flares to left main on the right side. So both the LAD and stent flares are fully expanding with the result of significant prolapse of plaque note similar to formation. And also, the ostia to the left main was fully covered by LAD to left main stent. So, finally, there are a several key points of DK crush stenting. A short protrusion of some flares into the left main balloon crush using appropriate size according to the left main (indistinct), rewire into stent flares, usually from proximal cell. For some cases, we can rewire from middle cell with alternative inflation before each kissing inflation. First kissing, following by rewire to the stenting LAD to left main after rewire again into the solid branch, alternative inflation followed by second kissing balloon inflation and the POT technique. Thank you very much. <v ->Well, that was a extremely elegant example</v> of the DK crush and it was a phenomenal result.

Dr. Chen

case study

DK crush technique

stenting

balloon inflation