LAD ve Sirkumfleks Ostiyumlarını İçeren Kompleks Sol Ana Koroner Arter Bifurkasyon Lezyonunda IVUS Kılavuzluğunda Başarılı DK-Crush Stentleme
Özet
Sol ana koroner arter (LMCA) ve kompleks bifurkasyon lezyonlarının yönetimi, girişimsel kardiyoloji pratiğinde yüksek riskli senaryolar arasında yer almaktadır. Bu bölümde; akut koroner sendrom prezentasyonu olan, anatomik kompleksitesi bağlamında yüksek SYNTAX skoruna (26) sahip ve cerrahi revaskülarizasyonu reddeden 52 yaşındaki erkek bir hastanın güncel kılavuzlar doğrultusunda başarılı perkütan yönetimi sunulmaktadır. İki boyutlu anjiyografinin diagnostik kısıtlılıkları aşılmak suretiyle uygulanan intravasküler ultrasonografi (IVUS) değerlendirmesinde; distal LMCA, sol ön inen arter (LAD) ve sirkumfleks arter (LCx) ostiyumlarını kapsayan kritik lümen darlığı, ağır aterosklerotik plak yükü ve uygun bir landing zone eksikliği kantitatif olarak saptanmıştır. Anatomik zorluk derecesi, eşlik eden kalsifikasyon paterni ve LCx ostiyal lezyonunun morfolojik özellikleri (darlık > %70) dikkate alınarak, planlı çift stent stratejisi olan Double Kissing Crush (DK-CRUSH) tekniği tercih edilmiştir. Stent ve balon boyutları, kalsifiye lezyon modifikasyonu ve ardışık optimizasyon protokolleri bütünüyle IVUS parametreleri rehberliğinde gerçekleştirilmiş olup; prosedür neticesinde stent malapozisyonu izlenmeksizin, güncel literatürce önerilen minimal stent alanı (MSA) hedeflerine komplikasyonsuz olarak ulaşılmıştır. Sunulan olgu, kompleks koroner anatomilerde cerrahiye alternatif teşkil eden yüksek riskli perkütan girişimlerde, ileri görüntüleme modalitelerinin ve DK-CRUSH tekniğinin optimal stent ekspansiyonu ile başarılı prosedürel sonlanım sağlamadaki kritik rolünü vurgulamaktadır.
The management of left main coronary artery (LMCA) and complex bifurcation lesions represents one of the highest-risk scenarios in interventional cardiology practice. This report presents the successful percutaneous management, guided by current clinical guidelines, of a 52-year-old male patient presenting with acute coronary syndrome, who had a high SYNTAX score (26) reflecting anatomical complexity and who declined surgical revascularization. To overcome the diagnostic limitations of two-dimensional angiography, intravascular ultrasound (IVUS) evaluation was performed, quantitatively demonstrating critical luminal stenosis, severe atherosclerotic plaque burden, and the absence of an optimal landing zone encompassing the distal LMCA, left anterior descending (LAD) artery, and circumflex (LCx) artery ostia. Taking into account the degree of anatomical complexity, the concomitant calcification pattern, and the morphological features of the LCx ostial lesion (stenosis > 70%), the Double Kissing Crush (DK-CRUSH) technique, a planned two-stent strategy, was elected. Stent and balloon sizing, calcific lesion modification, and sequential optimization protocols were conducted entirely under the guidance of IVUS parameters. Consequently, the minimal stent area (MSA) targets recommended by the current literature were achieved without any complications or stent malapposition. The presented case highlights the critical role of advanced imaging modalities and the DK-CRUSH technique in ensuring optimal stent expansion and a successful procedural outcome in high-risk percutaneous interventions serving as an alternative to surgery in complex coronary anatomies.
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