A Case of Imaging Guided Left Main PCI

A 57 year-old lady having a history of diabetes and hypertension. She presented with stable angina and a positive exercise treadmill test. Diagnostic angiogram showed moderate distal LM stenosis and tight ostial LAD stenosis involving the origin of the first diagonal branch (Movie 1). There was also ostial to proximal LCx disease (Movie 2). The distal RCA and PL branch had diffuse disease as well. PCI was performed to the left system first.

IVUS study was performed (Figure 1). Mid-LAD was then stented with a 2.25 x 28mm DES and proximal LAD with 2.5x28mm DES. Mid-LCX was stented with a 2.25×28 DES and proximal LCx with a 2.5x 15mm DES. A 3.5x23mm DES was deployed in the LM intentionally up to the ostium using the T-stent technique (Movie 3). The stent balloon was withdrawn out of the LM and post-dilated at 16 atm (Figure 2). The LCx was rewired. Sequential high pressure dilatation and kissing balloon inflation were performed. Post PCI IVUS showed the distal LM stent was well-apposed but the ostial LM was not covered with struts (Figure 3). A closer look showed there were 2 layers of struts at 12 o’clock position. The stent might have been collapsed longitudinally while the guiding catheter was engaged non-coaxially during LM stent balloon removal (Movie 4). The LM takeoff was angulated and the stent balloon might have been undersized to make engagement of the guiding catheter difficult. Another short stent was used to cover the LM ostium. A larger 4.0mm balloon was used for post-dilatation. IVUS study showed good ostial coverage. Final angiogram showed good final results (Movie 5). This case demonstrates the importance of careful engagement of guiding catheter after LM stent. An appropriate sized balloon can be used to engage the guiding catheter while the balloon is deflating.