Successful Bifurcation Stenting of the Posterior Descending Artery and Posterior Left Ventricular Artery in an Elderly Patient

CASE PRESENTATION Even in the technologically advanced era of percutaneous coronary intervention, the bifurcation stenting at the distal branches of the right coronary artery (RCA) remains a challenge. However, the present case represents a smooth and successful stenting in the distal branches of RCA in an elderly patient using a latest generation highly flexible (long dual Z-link connectors), biodegradable polymer-coated Supraflex Cruz sirolimus-eluting stent (SES). A 70-year-old male with hypertension and diabetes presented with complaints of chest pain, breathing difficulty, and mild cough. He had a recent history of non-ST-elevation myocardial infarction and triple-vessel disease-deferred coronary artery bypass grafting. On admission, the patient was diagnosed with acute left ventricular failure with pulmonary edema, pneumonia with sepsis, unstable angina, and accelerated hypertension (210/110 mmHg). A coronary angiogram revealed major stenosis in RCA Figure 1. Hence, revascularization of the posterior descending artery (PDA) and posterior left ventricular artery (PLV) of RCA was planned. A 2.5 mm × 12 mm Supraflex Cruz SES was deployed in PDA at 12 atm and another Supraflex Cruz SES was deployed in RCA-PLV at 12 atm. The proximal optimization technique was performed at RCA-PLV Figure 2. The kissing balloon was inflated using a 2.5 mm × 15 mm balloon in PDA and a 3.5 mm × 12 mm balloon in RCA-PLV at 14 atm. Post stent TIMI III flow was achieved Figure 3. The present case complied with the Declaration of Helsinki (as revised in 2013). The patient provided written informed consent for publication of this case and accompanying images.Figure 1: Coronary angiography showing: 70% stenosis at mid RCA, 90% stenosis at distal RCA, 90% stenosis at large PLV and 90% stenosis at ostium of PDA.Figure 2: Coronary angiography showing: (a) Ostium of the RCA engaged with JR 3.5 × 7 Fr and PDA and PLV lesions were crossed with two BMW guidewire. Sequentially, pre dilatation of proximal PLV to mid-RCA was done using a 2.5 mm × 15 mm Sapphire NC balloon and pre dilatation of PDA was done using a 2.0 mm × 10 mm Sapphire NC balloon; (b) Keeping a 2.5 mm × 15 mm Sapphire NC balloon in RCA-PLV across the PDA origin, a 2.5 mm × 12 mm Supraflex Cruz sirolimus-eluting stent (SES) was negotiated in PDA at 12 atm; (c) Balloon dilatation was done to crush the proximal part of PDA stent in RCA; (d) Again, sequential pre dilatation was done at proximal PLV to mid-RCA using 2.5 mm × 15 mm Sapphire NC balloon; (e) a 3.0 mm × 40 mm Supraflex Cruz SES was negotiated in the RCA-PLV at 12 atm, and post dilatation was done using 3.5 mm × 12 mm Sapphire NC balloon at 14 atm. (f) Post dilatation, the proximal optimization technique was performed at RCA-PLV.Figure 3: Coronary angiography showing: (a) Angiogram revealed stenosis at the ostium of the PDA after main branch stenting; (b) BMW wire was introduced to cross through the struts of a 3.0 mm × 40 mm stent in the RCA-PLV but was unable to cross; (c) Thus, a Whisper guidewire was used to cross the lesion; (d) Strut dilatation was done using 1.5 mm × 10 mm Sapphire pro balloon; (e) Kissing balloon was inflated using 2.5 × 15 mm Sapphire NC balloon in PDA and a 3.5 mm × 12 mm Sapphire NC balloon at 14 atm in the RCA-PLV and sequentially post dilatation was done in RCA-PLV at 14, 16, and 18 atm; (f) Post stent TIMI III flow achieved at bifurcation.Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.