August 7th 2017

ISR x Bifurcation lesion

Category: Complex PCI, Coronary,



Wishnu Aditya Jakarta Heart Center



Wishnu Aditya Jakarta Heart Center

Clinical Information
A 59 years old male was admitted in Nov 16 Due to Inferior STEMI 8 hours of onset. He had history of PCI to LAD in 2014. Primary PCI was performed with 1 DES implanted in distal RCA - RPL

Video 1. Primary PCI to RCA

VIdeo 2. Primary PCI Result

7 months after patient was planning for Hajj Pilgrimage and will have elective PCI to left coronary. On evaluation, significant instent restenosis in previous RCA stent was found, while left coronary lesion relatively unchanged.

Video 3. Tight ISR Bifurcation lesion in dRCA


We planned to open the ISR lesion while keeping the side branch open' since PDA is supplying a large are. Wiring to RPDA and RPL, continued with predilation to RPL and RPDA with 1.5 mm balloon. Further predilation to both branches with 2.5 mm NC balloon. DEB was implanted in dRCA-RAV Groove for 45 seconds. Patient had chest pain and inferior ST Elevation when the balloon was dilated. 

Video 4. Wiring, Predilation in RPDA and RPL

Video 5. DEB Inflated for 45 Seconds

DES was implanted in dRCA to RPDA, crossing previous stent (similar to culotte placement). After that, wire recrossing, new stent strut predilation, and kissing balloon was performed

Video 6. New DES implanted in dRCA-RPDA

Video 7. Kissing Balloon

Additional 1 DES was implanted in proximal RCA due to significant stenosis, and another 1 DES implanted in mid RCA due to spiral dissection. Final angiography showed good result

Video 8. Additional DES in pRCA and mRCA

Video 9. Final angiography


ISR, especially DES ISR is still an unresolved problem; widely adapted treatment including DEB and putting new DES. For ISR lesion with bifurcation, best treatment is still unknown.


In this case we performed Hybrid DES / DEB in ISR true bifurcation lesion with an acceptable result. Yet long term outcome of our procedure is yet to be evaluated.