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Case 173: Manual of PCI - STAR to the rescue

An elderly patient with multiple prior PCIs was referred for urgent coronary angiography due to unstable angina. He had a 90% mid LAD lesion involving the origin of a large 2nd diagonal branch. After wiring the LAD, 1st and 2nd diagonal provisional stenting was performed with a 3.0 mm stent that resulted in decreased flow in the 2nd diagonal. There was also a lesion, likely due to dissection, at the distal stent edge. Despite using a Sasuke dual lumen microcatheter and multiple guidewires we were unable to wire the 2nd diagonal. We were also unable to advance a 1.0 mm Sapphire Pro over the jailed wire, but were successful in advancing a 1.5 mm Takeru balloon using a guide extension. After dilation with the 1.5 mm balloon, we were able to wire the 2nd diagonal with a Sion black through the Sasuke. We stented the distal edge of the LAD followed by kissing balloon inflation in the LAD and 2nd diagonal but flow in the 2nd diagonal remained poor. We stented the 2nd diagonal using the culotte technique but flow remained poor. IVUS showed extraplaque (subintimal) stenting. The Sion black wire was knuckled and advanced distally until it re-entered into the distal true lumen (STAR technique) restoring TIMI 3 flow in the 2nd diagonal.