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.

[@Timothy-Walker]

STAR method = (Subintimal Tracking and Reentry) with a Sion Black wire. Your cases are always educational and informative Dr. Brilakis. Thank you.

[@shangz0216]

Thanks for sharing.

[@llacielona]

is STAR technique for such cases, always successful? are there limitation to this techique?

[@viktorsasi7453]

Modified jailed balloon would have helped to keep sufficient flow. Acs situation for sure, Manos consider my idea and contact.5

[@manosbrilakis]

Great point, thank you

[@user-zm9rj2so5r]

Is possible that diagonal rewairing with dlmc was subintimal

[@mahmoud_elrayes]

Excellent innovative safe after stenting. I have a question: In case of poor flow, do you prefer to do IVUS, especially after dilation with a jailed balloon, to clarify the mechanism before stenting? Thanks

[@manosbrilakis]

Excellent point - IVUS can definitely help understand the reason for no flow

[@user-ft2rw7vo2n]

STAR: Pushed the leash hard on Knuckle? Can't the hematoma compromise the visualization of the vessel? What is the ideal wire for this?

[@manosbrilakis]

Pushing is quite hard when doing STAR: Mongo or Fielder XT are my preferred wires for STAR.

[@laurentiu5906]

Thank you for the case Dr Brilakis. Will that diagonal remain patent over time ?

[@manosbrilakis]

Hopefully!