Posts Tagged ‘carina of coronary artery’

Kissing balloon is the standard technique used to tackle   branch vessel stenosis . When a vessel branches out and both branches has a lesion,  single balloon can not dilate a lesion optimally . This  is  because , the side branch  not only shares a common ostial tissue but also  shares  plaque material within the walls of main and side  vessel . Dilating one vessel alone could result in unpredictable plaque shift.

Carina is the most important anatomic structure in a bifurcation zone . It acts like a grade separator. Diverting and deflecting blood flow .The  length and angle of this grade separator determine the ostial  shape as well . A right angled side branch will have  a circular ostium .An acute-angled branch  will have oval orifice .  The plaque burden and distributions at this point becomes vital for many reasons.

When we do PCI this carinal area should be  optimally pressed and plastied  and of course covered well with the metal struts.The  simultaneous kissing with two balloons ,  one in main vessel another in side branch will reduce many of the issues . This area is a weak link for interventional cardiologists. It needs lots of efforts to protect the side vessel.

When do we do kissing balloon ?

Two broad categories.

  • Pre-dilatation and preparing a lesion ( Not routine  )
  • Post dilatation is more often done .

Look closely the layers of contention in the carinal zone. Lesion not depicted .

Kissing interface : When the balloons kiss  what lies  in between ?

  1. Simple  Balloon to Balloon Kissing with nothing intervening(Proximal to branch point )
  2. Balloon- Single layer of Stent-balloon kissing
  3. Carinal  Kissing -Balloon -Two layers of Carinal tissue -one layer of Stent -Balloon Kissing ( See above image )
  4. Twin stent kissing

When do  balloons refuse to Kiss ?

When there is a hard interface between the vessels like a severely  calcified intima /Adventia .

Eccentric /overhanging  lesions intervening.

Incomplete kiss

It need to be emphasized balloons come  into contact easily in  acute-angled lesions.

In right  angled lesions the balloons come to contact only in the proximal part.

Definite indications  for  kissing ?

Kissing is not without complications . While two guide wires are placed in all  bifurcation lesions  , kissing is  not necessary in many  lesions  .Of course it is a must in all true bifurcation lesions (Medina 111 , 011, 101, )  It may not be required in  1,0,0 if carina is away from lesion.

*Kissing can rarely aggravate the same issue which is supposed to prevent  ie plaque shift .This is due to differential pressure transmission by two balloons.

Is there a role for  twin balloon POBA  without any stenting ?

Most cardiologists would not believe  in POBA anyore (For wrong reasons though ! )

A distal RCA with a PDA ostial branch lesion could be tackled with twin balloon POBA.

Which  balloon is to be used?

It depends on whether we use the technique  as POBA, single stent or double stent technique. Non compliant balloons are  ideal  as it exerts   more pressure on the vessel wall .

Kissing   at  what  pressure ?

The pressure used is often between 8-14 ATM.

Experts may use differential pressure inflation depending on the lesion characters.

Which  is the Most complex form of kissing ?  

Two stents, two balloons . Here the interface contains two metal layers . At carnia the two metals engulf   two layers of  tissue as well .

Final message

Bifurcation lesions  are being  conquered with more success in recent years.

The techniques have refined. Stent designs and drug eluting stents  are  helping us in many ways.

We have learnt  from our  mistakes and accepted the limitations.

Wisdom  prevails now , there is a universal consensus  for less  metal in the notorious  carinal  area.

Still, ignorance  remains*  as  a major  guiding force   . . . when  we  navigate  the difficult atheromatous terrains  in  live human  coronary arteries !

*With due respects to IVUS, OCT and FFR .

**Forward looking IVUS, and camera tipped guidewires may change the scenerio.


Further reading

What-is-the-simple-approach-to-bifurcation-pci ?

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