İzole Osteal Lezyonlarda Perkutan Koroner Girişim; Inverted Provizyonel T Stentleme
Özet
Koroner bifurkasyon lezyonlarının nadir bir türü olan medina (0,0,1) izole osteal yan dal lezyonlarının perkütan koroner girişim (PKG) ile tedavisi, ana damar yaralanması ve stent restenozu gibi riskler nedeniyle girişimsel kardiyolojide halen tartışmalı bir konudur. Bu tür vakalarda hasta bazlı yaklaşım ön planda olup; lezyon morfolojisi, damar çapı ve kalsifikasyon durumu tercih edilecek stratejiyi doğrudan etkilemektedir. Sunulan vakada, 67 yaşında anstabil anjina pektoris tanısı alan ve Diagonal-1 arterinde %95 osteal darlık saptanan bir erkek hastanın tedavi süreci aktarılmıştır. Ana dal ile yan dal arasında belirgin çap farkı ve geniş bir bifurkasyon açısı bulunmaması sebebiyle hastaya "inverted provizyonel T stentleme" tekniği uygulanmıştır. İşlem sırasında balon predilatasyonu, ilaç salınımlı stent implantasyonu, proksimal optimizasyon (POT) ve kissing balon adımları başarıyla yürütülmüştür. Komplikasyonsuz tamamlanan girişimin ardından yapılan final anjiyogramda tam açıklık sağlanmış ve hastanın 1. yıl takibinde asemptomatik kaldığı gözlenmiştir. Klasik balon, ilaç kaplı balon, Szabo ve crush gibi alternatif yöntemler de mevcut olmakla birlikte, uygun anatömide inverted provizyonel tekniğin tam osteal kapsama sağladığı ve hedef damar revaskülarizasyon sıklığını düşürdüğü vurgulanmaktadır.
Percutaneous coronary intervention (PCI) for medina (0,0,1) isolated ostial side branch lesions represents a complex and controversial area in interventional cardiology due to risks of main vessel injury and stent restenosis. Management requires a patient-specific approach evaluating vessel diameters, lesion length, and tissue calcification. In the reported case, a 67-year-old male presenting with unstable angina pectoris was diagnosed with a 95% ostial stenosis in the Diagonal-1 artery. Given the absence of a significant diameter mismatch and a wide bifurcation angle, the patient was treated using the "inverted provisional T stenting" technique. The procedure successfully incorporated sequential balloon predilation, drug-eluting stent implantation, proximal optimization (POT), and kissing balloon inflation. Post-procedural angiograms confirmed optimal vessel patency without residual stenosis, and the patient remained entirely asymptomatic at the 1-year clinical follow-up. While alternative strategies such as drug-coated balloons, flush ostial, Szabo, and crush techniques exist, the inverted provisional approach is highlighted for providing complete ostial coverage with low target lesion revascularization rates in suitable anatomy.
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