By Dr. Naeem Tahirkheli
Oklahoma, USA
Talking JSKBT ( jailed semi inflated kissing balloon technique ) We did multiple JSKBTs here. Zameer our Pakistani fellow made these images.
Patient had CP/ NSTEMI in a decent sized town 100 miles away. Which has good sized hospital and interventional cardiologist’s and PCIs / primary etc are done. No CABG onsite. Cardiologist did angio for intervention purposes. Saw the anatomy
Calcified distal left main, Ostial/ prox / mid LAD, 90% tight ramus, 90% bifurcation LCX/OM1 and CTO RCA. EF 30% with severe MR ( so even poorer forward flow / and overestimation of the LV function due to MR).
Referred to our surgeon. He said he can ! But very high risk. ( calcified aorta not. Great candidate to put on heart lung bypass / previous EVAR, Poor LV function, ) so referred to one of our colleagues – who said very high risk PCI. Referred back to surgery. Nothing happened. Meanwhile patient having symptoms. So the primary interventional cardiologist from the other city called us.
Was going to need 3 to 4 wires with multiple balloons at a time. So needed an 8 French guide so did do single access Impella. Also deliberately took a short JL 3.5 guide ( which obviously has low support ) so we can sit outside this shortish left main and work
LAD was quite retroflex so you can appreciate flipping of hydrophilic coated wire with >120 bend with microcatheter assistance. Later changed to wiggle wire; So onwards LAD was started. Calcified, retroflex and quite some tortuous so IVUS was done after first run of 2.5 pre-dil;
Still there was IVUS malfunction in mid autorun so predilated with 3.0 balloon and ReIVUS
Heavy more than 270 degrees calcium is there;
Further vessel preparation was done with 3.0 IVL all the way upto LMS
This is tight LCX and tight OM1. Kissing balloon inflations and then stent in LCX and JSKBT is OM. Notice 4 wires in there. Pretty good result. OM Latium looks really good. IVUD of LCX stent good. Did POT of the proximal LCX with NC balloon; This is the long 3.0 x 48 synergy xl. Extending from mid LAD to left main and have 3.0 x 15 balloons as JSKBTs in Intermediate and LCX
Couldn’t get the IVUS to distal edge to see if it is dissection or spasm. These new Hi Def boston IVUS shafts are flimsy and you push them and they get bent. Used three different catheters during this long intervention. Cuz it would get stuck in calcium and then either stop working or the shaft get bent. So images look like distal edge dissection. Placed a 2.5 mm shirt stent. Looked good after wards
IVUS from LAD stent back to left main. Had also done a 4.5 x 6 mm short NC balloon POT for left main. ( size mismatch between left main and LAD)
Of course without Impella. Wouldn’t have been able to do these. With occluded RCA and EF 30% with severe MR. I was getting flat line pressures with IVL and Thenleft main stenting with JSKBTs
The End
GlobeMedic 