Mr SS

A 70-year-old male, non-smoker with background history of diabetes mellitus, hypertension, benign prostate hypertrophy, and end stage renal disease on regular haemodialysis presented with multiple admissions of unstable angina and NSTEMI.Patient developed hypotension due to poor tolerability with haemodialysis. Therefore, he was switched to peritoneal dialysis.His Blood pressure was 106/60 mmHg and pulse rate was 62/min.Respiratory examination revealed bibasal crepitation.

Blood investigations showed Hb of 12.1g/dl, creatinine 603 μmol/L, troponin T 2265.Echocardiography examination revealed reduced left ventricular function with ejection fraction of 40%, dilated left atrial, global hypokinetic and there was no clot or thrombus observed.There was also no pericardial effusion observed.ECG showed LVH pattern and T wave inversion V2 to V6.Chest X-ray showed cardiomegaly.
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Coronary angiography showed LMT 50% stenosis, prox and mid LAD 90%, D1 artery 70% stenosis, and diffuse LCX disease where the ostial to distal is 70 % to 90% with medina classification 1,1,1 (LMT, LAD & LCX).He was referred for inpatient CABG and his calculated Society of Thoracic Surgeons (STS) risk score for mortality is 5% and Syntax Score is 32.However, after a discussion on his risk of CABG, the patient refused to undergo CABG procedure.Taking patient decision into consideration, we proceed to high risk PCI.
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The right femoral artery (RFA) was punctured. IABP was on standby mode. 
A 7Fr JL 4 was used to engage LMT. A BMW II J tip wire was inserted into LCx and another wire runthrough floppy wired down to LAD. The LCx was predilated by NC 2.5x12mm balloon.Long LCx lesions was treated with Sirolimus-coated balloons (SCB) (2.5x30mm, 2.5x20mm, 2.75x20mm). LAD was predilated using a 3.0x15mm NC balloon.The mid LAD lesion was treated with drug-eluting stents (DES, 2.75x38mm). LMT and proximal LAD were treated with DES (4.0x32mm).IVUS was performed.Post-dilated LMT with 4.5x8mm NC balloon and LAD with 4.0x15mm NC balloon. Sequential balloon dilatation at proximal LAD with 4.0x15mm NC balloon and proximal LCx with 3.0x12mm NC balloon. Final kissing balloon of proximal LAD and LCx.Final POT at LMT with 4.5x8mm NC balloon. IVUS was performed again.Good result. Patient underwent heamodialysis well and his functional status improved remarkably after revascularization.

PCI is an alternative treatment strategy for high surgical risk patients, especially with ESRD & recurrent NSTEMI For significant ostial Lcx involvement, 2 stents strategy is recommended, however, in patient with ESRD, the In-stent restenosis rate is very high. Several studies reported that, compared with 2-stent techniques, the provisional 1-stent strategy for LM bifurcation was associated with better outcomes, lower risks of major adverse cardiac events, death & MI. The stenting strategy is an important prognostic factor when deciding the optimal revascularization treatment. Imaging such as IVUS is vital as the vessel size can be underestimated using angiographic interpretation.