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Dilation of Bifurcation Stenoses

      I read with interest the article by O'Keefe and associates, “A New Approach for Dilation of Bifurcation Stenoses: The Dual Probe Technique,” in the March 1989 issue of the Proceedings (pages 277 to 281). I have also used this technique in several patients; the “Probe” catheter (United States Catheter and Instrument Company [USCI], Billerica, Massachusetts) or the similar, recently introduced, “ACE” balloon-on-a-wire catheter (SciMed) has produced salutary results in bifurcation coronary artery lesions.
      The authors suggest the introduction of both balloons through a triple-lumen device called a Duostat (Advanced Cardiovascular Systems, Mountain View, California). Careful inspection of the photograph of this device in the article by O'Keefe and colleagues reveals a potential problem with the Duostat—namely, that the dilation catheter introduced through the angled (outermost) port must negotiate a bend of approximately 150°. In the illustration (Figure 3 in their article), only the soft, flexible, “plastic” portion of the dilating catheter is shown passing through this angled adapter port. In use, however, the proximal solid metal tubular portion of the catheter must also accommodate this bend, and in my experience, attempting to use this same adapter device has caused considerable resistance to the movement of the dilating balloon catheter.
      Alternatively, I have found that both Probes can be introduced, side by side, into the guiding catheter through the common central lumen of the standard Tuohy-Borst adapter (USCI). This technique avoids bending of either Probe, allows adequate freedom of movement of either catheter, and results in minimal back-bleeding. Furthermore, my colleagues and I have been able to introduce the Probes independently and to place them selectively in the coronary branches to be dilated, rather than introducing the catheters together as the authors suggest; thus, confusion about which is which can be avoided. The only potential problem with this approach is that care must be taken to avoid damage to the distal guiding wire on the second Probe as it is introduced into the Tuohy-Borst adapter.
      The authors should be commended for bringing this useful technique for dilation of difficult bifurcation lesions to the attention of coronary angioplasty operators.

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      • Dilation of Bifurcation Stenoses: Dr. Holmes replies
        Mayo Clinic ProceedingsVol. 64Issue 8
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          My coauthors and I appreciate Dr. Brymer's letter. Dr. Brymer does point out that the Duostat is not a perfect device. The bend through the angled port may be difficult to negotiate. In our experience, however, we have been able to accomplish this maneuver. The technique of using a standard Tuohy-Borst adapter, as described by Dr. Brymer, can also be helpful as suggested. The increasing number of possible approaches helps to facilitate dilation of bifurcation stenoses and expands the number of patients in whom percutaneous transluminal coronary angioplasty is an attractive therapeutic option.
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