A 58-year-old male presented to our emergency department with signs and symptoms of non-ST-elevation myocardial infarction. The patient underwent invasive coronary angiography, which revealed non-left main bifurcation disease, involving the left anterior descending (LAD) and first diagonal (D1) arteries, as well as critical stenosis of the left circumflex artery (Figure 1a, Supplementary Video 1). After passing the proximal LAD artery lesion with a guidewire, intravascular ultrasound (IVUS) revealed severe calcification in the LAD artery (Figure 1b). Although the D1 artery was successfully predilated (Figure 1c), the LAD artery was not optimally predilated (Figure 1d). Thereafter, the lesion was successfully prepared using the wire-cutting technique (Figure 1e, Supplementary Video 2), and a 2.5 × 31 mm drug-eluting stent [(DES); Firehawk, MicroPort Scientific Inc., Shanghai, China] was implanted from the D1 artery to the LAD artery with minimal protrusion (1-2 mm) (Figure 1f, Supplementary Video 3). The proximal side-branch optimization technique was applied by gently retracting the D1 stent balloon (Figure 2a), and kissing balloon inflation (KBI) was performed (Figure 2b, Supplementary Video 4). Thereafter, the D1 stent balloon was slowly deflated, and the D1 stent was crushed in a controlled manner (Figure 2c, Supplementary Video 5). Optimal crushing and coverage of the D1 stent were confirmed via IVUS (Figure 2d, Supplementary Video 6, 7) and ClearStent (Siemens, Germany) (Figure 2e). For the LAD artery lesion, a 3.0 × 38 mm DES was implanted at 12 atm (Figure 2f). The proximal optimization technique (POT) was performed (Figure 3a, b), and after rewiring, the 1.5 × 20 mm semi-compliant balloon was easily advanced into the D1 artery (Supplementary Video 8). After the final KBI and re-POT (Figure 3c, d), the stent position was assessed using ClearStent and IVUS. The stent apposition was found to be optimal (Figure 3e, f, Supplementary Video 9). Thus, the procedure was completed (Figure 3g, Supplementary Video 10, 11). The same technique was successfully performed in two other patients (Supplementary Figure 1, 2).

The crush technique is one of the leading double-stent techniques frequently performed by numerous interventional cardiologists for treating complex bifurcation lesions.¹ It remains popular with several iterations having emerged in the past two decades. However, the most important challenges of the crush techniques are the rewiring and advancement of a side-branch balloon after the main branch stent has been implanted.^2,3 Therefore, we believe that our novel approach may overcome these disadvantages.

Informed Consent: A detailed written informed consent was obtained from the patient for the publication of this case and images.

Authorship Contributions: Concept- F.U., A.G., A.Y.Ç.; Design- F.U., A.G.; Supervision- F.U.; Materials- A.G.; Data Collection and/or Processing- A.Y.Ç., K.Ç.; Literature Search- F.U., A.G., A.Y.Ç.; Writing- F.U., A.G.; Critical Review- İ.F.A.

Conflict of Interest: No conflict of interest was declared by the authors.

SUPPLEMENTARY FIG 1 AND FIG 2. https://balkanmedicaljournal.org/uploads/pdf/1SUPLEMENT-FIG.pdf

REFERENCES

1. Moroni F, Shue-Min Yeh J, Attallah A, et al. Crush techniques for percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2022;18:71-82.
2. Güner A, Uzun F, Demirci G, et al. Cardiovascular outcomes after mini-crush or double kissing crush stenting techniques for complex bifurcation lesions: the EVOLUTE-CRUSH registry. Am J Cardiol. 2023;206:238-246.
3. Güner A, Uzun F, Çizgici AY, et al. Long-term cardiovascular outcomes after mini-crush or T and minimal protrusion techniques in complex bifurcation lesions: the EVOLUTE-CRUSH III study. Coron Artery Dis. 2024;35:641-649.