Complex LMCA PCI with 2 side branches diseased

PCI has taken a more prominent role in the treatment of Left Main Coronary Artery (LMCA) disease. Despite advances in LMCA intervention, treatment of distal Left Main bifurcation remains technically challenging. Obtaining a successful treatment result in PCI for a Left Main bifurcation requires the use of Drug-Eluting Stent (DES) technology suited for this application paired with optimized implantation technique.

Patient History

• 83 years old man
• Cardiovascular risk factors: current smokers, dyslipidemia
• Symptoms : ACS without ST elevation , tropo +
• Clearance creatinine: 83 ml/min
• TTE: LVEF : 65%

Description of Lesion

Right coronary artery presents with atheromatous plaques. 
Multi vessel disease in left artery, complex stenosis of distal LMCA and proximal LAD with stenosis in trifurcation in both diagonals and a short circumflex artery.
There is an in-stent restenosis in a BMS (2013) in proximal LAD.

Complex angioplasty

Left radial approach. 7F guiding catheter. Introduction of a Sion Blue guidewire in the LAD. Difficulty to cross the second diagonal ostial lesion given an important curve, different strategies attempted: a Sion guidewire, a soft tapered guide wire (Fielder XT), a stiffer guide wire (Pilot 50) and then finally succeeded with Finecross microcatheter and a Fielder XT soft guide. First predilatation of the ostial part of the second diagonal branch with a Sapphire II Pro balloon (1.0x10mm), then with a larger balloon (1.5 x 20mm) through the entire angulation and finally succeeded with a Euphora balloon (2.5x20mm). Successful implantation of a drug-eluting stent Resolute Onyx™ (2.5x26mm) in "T-stenting" technic. Finalize with a kissing balloon technic in proximal LAD (with 3.5mm balloon) through the previous BMS and then in the diagonal (with the balloon of the stent, 2.5mm).

First diagonal treated by use of extension guiding catheter GuideLiner for predilatation in order to lead and implant a drug-eluting stent Resolute Onyx™ (2.75x18mm) in a "T-stenting" bifurcation technic in the 1st diagonal branch.

Last, treat the LMCA (estimated at 5.5mm) and proximal LAD: LMCA predilatation, implantation of a drug-eluting stent Resolute Onyx™ (4.5x26mm, can be expended to 5.75mm) in LMCA to proximal LAD, joined with the proximal LAD stent, LMCA post-dilatation with a 5mm balloon deployed to 5.5.mm. No final kissing or dilatation to the LCX, 1st obtus marginal and diagonal.

A good angiographic result at the end of the procedure with Stentboost

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