CLH

A 68-year-old female with hypertension, non-valvular paroxysmal atrial fibrillation and breast cancer post mastectomy had presented with multiple episodes of resting angina and dyspnoea. She had no heart failure symptoms and was hemodynamically stable. Physical examination was unremarkable. She was promptly diagnosed with unstable angina and proceeded for inpatient coronary angiography.

Haemoglobin level was low at 10.6 g/dlPlatelet count normal at 223 x 10⁹/LCreatinine impaired at 124 µmol/LInternational Normalised Ratio 1.0Troponin I normal at 6.5 ng/LElectrocardiogram showed rate controlled atrial fibrillation with ST depression over anterior leadsHer resting echocardiogram demonstrated preserved left ventricular ejection fraction of 74 %, with no obvious regional wall motion abnormality.

Angiography revealed very short left main (LM) with resultant selective engagement of diagnostic catheter. Left anterior descending artery (LAD) had 90 % stenosis at ostium with acute 90 degrees angulated take off from left main. There was minimal angiographic calcification. Proximal left circumflex artery (LCX) had 70 % stenosis while right coronary artery (RCA) was dominant with 50 % stenosis at proximal region.

IVUS guided intervention involving LM was planned. Vascular access obtained via right radial. XB 3.0 6 French (Cordis, U.S) catheter carefully manipulated to engage LM as selective intubation into ostial LAD plaque may risk dissection. Guider position stabilised by foremost wiring LCX with Runthrough Floppy (Terumo, Japan), followed by wiring LAD with second Runthrough Floppy. Upfront IVUS run of LCX and LAD done. Proximal LCX had 70 % plaque with vessel size 3.2 mm while ostial LAD had 90 % plaque with vessel size 4.4 mm and superficial calcification < 180 degrees. Provisional approach of LM to LAD stenting was planned. Due to inevitable jailing of LCX, proximal LCX lesion was intervened first. LCX was predilated with Emerge 2.5 x 15 mm (Boston, U.S) at 16 atm and stented with Promus Elite 3.0 x 20 mm (Boston, U.S) followed by postdilatation with NC Emerge 3.0 x 12 mm (Boston,U.S) at 16 atm. Ostial LAD incrementally predilated due to watermelon seeding with Emerge 2.5 x 15 mm up to 22 atm. Due to short LM and difficulty identifying aorto-ostial junction angiographically, a sepal wire technique using Runthrough Floppy was used to guide ostial LM stent placement and prevent guider engagement. Ostial LM to LAD stented with Promus Elite 4.0 x 12 mm and flared with NC Emerge 4.0 x 8 mm up to 22 atm. Final IVUS run showed no edge dissection with good stent apposition and expansion. LM minimum luminal area was 13.4 mm², while LAD minimum luminal area was 11.5 mm².

Very short LM with ostial LAD stenosis intervention posed some unique challenges. Selective guider engagement bias into ostial LAD plaque may potentially risk dissection. In provisional LM to LAD stenting, side branch lesion should be treated first to avoid jailing LCX for future access. In short LM with ambiguous aorto-ostial junction angiographically, sepal wire may guide accurate stent placement while preventing guider engagement. LM intervention should be imaging guided, preferentially IVUS, for stent size selection and optimisation.