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Primary PCI of LAD/D occlusion with Invatec Avion Bifurcation balloon
Interventional cardiologist Dr. Ferdinand Kiemeneij
Center Amsterdam Department of Interventional Cardiology- Onze Lieve Vrouwe Gasthuis
History An 87 year old female was referred for primary PCI because of an acute (3 hours) anterior infarction. Despite her age clinically and hemodynamically this patient was in good condition.   
Strategy

The usual strategy followed for primary PCI in our center is as follows: Transradial approach, IIbIIIa blockade, use of an aspiration catheter in case of a thrombotic occlusion followed by direct stenting.
Procedure

A 6F Terumo sheath was placed in the radial artery followed by cannulation of the LCA wth a Kimny Mach 1 catheter (Boston Scientific). Angiography revealed a thrombotic occlusion of the LAD/diagonal bifurcation with complete occlusion of the LAD and partial filling of the diagonal branch (fig. 1). Both branches were wired with Biotronik Galeo Hydro F wires. An attempt to reach the thrombus with a Medtronic aspiration catheter failed. This attempt was followed by dilatation of the lesion with an Invatec Avion bifurcation balloon (3.0/2.5 mm) which crossed the lesion without problems (fig. 2). The result at the occlusion site after 20 seconds inflation was perfect and smooth (fig. 3). However, the very apical part of the LAD remained occluded, as  well as the distal part of the diagonal branch possible because of distal embolization. Although I usually stent during primary PCI, in this situation I considered the balloon result as acceptable, thus bypassing the risk of no reflow and of side branch occlusion after stenting.

Total procedural time, including RCA angiography was 19 minutes with a flouorotime of 7.2 minutes.

The patient was treated with aggrastat postPCI and returned to the referring hospital 2 hours later.

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Comments This case shows several important issues: First the fact that primary PCI is done via the radial artery. This is the preferred entry site since it decreases bleeding complications in patients revceiving a combination of aspirin, clopidogrel, IIbIIIa blockers and heparin. Second the use of an aspiration catheter for primary PCI is routine in our department. It allows better judgement of the lesion and reduces the risk of distal embolisation or no reflow. Unfortunately, in this patient I was not able to reach the lesion, possibly because 2 wires were used. The apical LAD and the distal part of the diagonal branch remained occluded possibly because of distal embolization. Third, with the bifurcation balloon it was easily possible to restore patency of both the main branch and the side branch in one single action. This contributed to the short procedural time.