Double guide double wrist 5F left coronary artery transradial percutaneous coronary intervention and the X-Kiss technique

Figures & data

Table 1.  

M/F	M	F	M	F	F
Age	81	70	86	87	89
BMI/Height (cm)/Weight (kg)	25/174/75	33/159/85	30/160/78	22/160/56	22/160/56
Frailty (0–3+)	2+	1+	3+	3+	3+
Symptoms at presentation	New chest pain and SOB CCVS Cl 3	Progression of chest pain, SOB CCVS Cl 3	Chest Pain and SOB CCVS Cl 4	Acute Pulmonary Edema NSTEMI VT, persistent HF	Acute Pulmonary Edema NSTEMI VT, persistent HF
Associated medical conditions	Severe COPD Gold IV, permanent O2 therapy	Severe COPD Gold III Past CVA & CAD	Valvular aortic stenosis, severe (< 1 cm2), COPD, transient AV block	HBP, Paroxysmal Atrial Fibrillation Low Ef (recent)	HBP, Diabetes, low Ef (recent)
CAD, Syntax score (SS)	distal LMCA. Medina 1,1,1 left dominance, SS 30	distal LMCA, medina 1,1,1 SS 23	distal LMCA, medina 1,1,1 occluded RCA (3VD), SS 48	LMCA equivalent CAD, balanced distribution,	3 VD, prox. & mid LAD a., 95% CX a., 75% RCa. lesion, SS 35
				Occluded RCA (3 VD), SS 28
addressed vessel(s)	LMCA	LMCA	LMCA	Ostial-LAD/ostial CX arteries	Prox to distal LAD-Diag a.
GFR (ml/h)/Hb (gr/dl)	40/14,5	60/12,9	49,5/14,9	53/10,4	42/11,1
Arterial Access	R TUA/L TRA, 5F GS	R + L TRA, 5F Glidesheath	R + L TRA, 5F Glidesheath	R + L TRA, 5F Glidesheath	R + L TRA, 5F Glidesheath
GC	Ikari L 3.5, EBU 3.5	Ikari L 3.5, EBU 3.5	Ikari L 3.5, EBU 3.5	Ikari L 3.5, EBU 3.5	Ikari L 3.5, EBU 3.5
stenting technique	Provisional stenting	Provisional stenting	T stenting	V stenting	provisional stenting
Anti-platelet therapy	On clopidogrel	On clopidogrel	On clopidogrel	On clopidogrel	On Clopidogrel + Tirofiban
Nber of Coronary Wires	5 Wires (Sion x 2, Blue, Pilot 50 & 150)	3 Wires (Sion x 2, Blue x 1)	4 Wires (Sion x 2, Blue x 2)	3 Wires (Sion x 2, Blue x 1)	4 Wires (Sion x 2, Blue, Pilot 50)
Balloon Kiss before stenting	LAD/CX a: 2.0–3.5	LAD/Cx a.: 2.5–1.25	LAD/CX a.: 3.5–2.5	(-)	LAD a/1st Diag: 2.5–1.5
Size of stents/POT/final kiss	DES 4–22 (LM-CX) POT 4.5–08 Kiss 2.0–3.5 LAD/CX a.	DES 3.5–18 (LM-LAD a.) POT 4.5–08	DES 4–18 (LM-LAD a.) POT 4.5–08 DES 3–09 ostial CX a. Re- Kiss 3.0–3.0 LAD/Cx a.	Kiss Stenting DES 3.0–18 LAD a/3.5 balloon CXa. Kiss Stenting DES 4–12 CX a/ 3.0 balloon LAD a	DES 3.0–15 + 3.0–09 + 2.5–28 POT nc 3.5–08 (D1 & D2)
Fluoro Time/Volume of Contrast/DAP/CPK 24h	44'/290 ml//228 Gy/cm2	17'/212 ml/143 Gy/cm2	20'/148 ml/114 Gy/cm2	15'/140 ml/73 Gy/cm2	20'/128 ml/173 Gy/cm2
	CPK (-)	CPK (-)	CPK (-)	CPK (-)	CPK (-)
FUup	alive at 1 year, acute pneumonia at 1 month	alive at 1 year, no angina	alive > 6 m, aortic valve stenosis said moderate	alive > 6 months, cl 1, normalized LV function	alive > 6 months, cl 1, normalized LV function (had 2 weeks re-hosp for HF)

Figure 1. (a) Case 1. Caudal right anterior oblique (RAO) coronary angiograms obtained in 2005 and 2015 revealing the appearance of a severe Medina 1,1,1 LMCA lesion. Result after provisional stenting. (b) Case 1. A triple X-kiss pattern is discovered at the balloons, Wires and Guiding catheters levels. Balloons and wires X-kissing was unexpected.

Figure 2. (a) Case 2. Caudal RAO and cranial LAO views before (a, b) and after stenting (c,d) a severe Medina 1,1,1 LMCA lesion, CX artery is a small-sized vessel. (b) Case 2. The triple X-kiss pattern (GCs, Wires and balloons) is again observed.

Figure 3. (a) Case 3. Cranial and caudal RAO views of a severe Medina 1,1,1 LMCA lesion before (a, b) and after T stenting (c, d). Early emergence of the first OM branch from the proximal CX artery and the large size of the vessels can be observed. View of the final X-kiss balloon inflation after T stenting (e). (b) Case 3. Triple X-kiss pattern again present. Triple wiring (LAD artery, CX artery, and first OM branch) was used for the trifurcated distal LMCA lesion.

Figure 4. Case 4. Caudal RAO views before and after LAD/CX artery stenting. Final kiss balloons view (“V-Pattern”), only the GCs X-kissed.

Figure 5. Case 5. Cranial RAO (40–10°) view of LCA, before and after distal, proximal and mid LAD artery stenting (P O T for LAD/Diag 2 and LAD/Diag 1 arteries).

Figure 6. X versus Y-kiss at the wires level: 1 Guiding Catheter versus 2 Guiding Catheters in LAO and RAO caudal views. Y-kiss wires views are extracted from records of previous single access TRA cases of distal LMCA PCI.