İK

A 54-year-old male patient with renal transplant(15 years ago) had complained persistent rest angina for2 days. These symptomsmissed to be associated with an acute myocardial infarction. His ECG showed STelevation from V1 to V3 and ST depression in D1,aVL, V1 and V6. He was anxiousand agitated. His BP was 110/70 mm Hg. Heartrate was 118 bpm and respiratoryrate was 26 per minute.  A subacute anterior infarction with post MI anginahad been suspected

Aspartate transaminase (105 U/L), Lactate dehydrogenase (290 U/L) andtroponin (6536 pg/ml) levels werehigh to indicate a myocardial injury. At the same time, the patient hadincreased blood urea (155.5 mg/dL) and creatinine (3.75 mg/dL) level, which decreased to 101 mg/dL and 2.24 mg/dL respectively after the procedure. Uric acid (12.5 mg/dL), glucose (134 mg/dL),  CRP (94.95 mg/dL) and leukocyte (12.490) were also elevated.   

Video 1. Right coronary artery.avi
Video 2. Left coronary system.avi
Video 3. LAD after predilataion.avi

A CTO lesion with good collateral flow in theRCA, subtotal occlusion of the LAD ostium and critical stenosis in the ramusbranch (RB). Emergency bypass was first planned due to pre-shock status.However, PCI was preferred after bedside consultation. Guiding catheter was6Fr. We planned stenting of the LAD alone and inserted a safety wire and a balloonin RB. LAD appeared at the end and further intervention was planned after viability tests. After PCI, he has good functional capacity w/o symptoms. 
Video 4. Double wire then safety balloon.avi
Video 5. LAD ostial stenting.avi
Video 6. Stent-Λ-Balloon Technique.avi

As far as we know, only few stenting techniques have been defined in the treatment of Medina 0,1,0 or 0,1,1 left main stenosis. LM-to-LAD crossover stenting is a good technique to treat LAD ostial stenosis, but many operators still want to put a stent just limited to LAD. In our technique, we impanted a 3.0x20  mm DES in the LAD ostium with 1-2 mm protrusion into the LM  after predilatation and performed final kissing ballooning with a 2.0x20 mm balloon which is already parked in the ramus branch. Precise stent placement in the LAD ostium is technically challenging. Excessive protrusion of the stent into LM might result in stent deformation and compromisation of future interventions. On the other hand, geographic miss leaving a portion of the lesion uncovered is related to edge dissection, restenosis, stent thrombosis. Szabo and Afzal's techniques are focal ostial stenting strategies which are developed to minimize incomplete lesion coverage (geographic miss) in the ostium. As expected in all techniques,  jailing or loss of side branch (LCX) due to plaque shift are inevitable in some circumtances . In Stent-Λ-Balloon Technique, a prompt intervention in such complications could be possible with a parked safety balloon, which is first used as a marker for stent positioning. Parked safety balloon could also be inflated simultaneously to prevent plaque shift or after stent implantation to improve carina and crush unnecessary stent protruding into left main over LCX. 
Video 7. Final angiography.avi

The name Stent-Λ-Balloon Technique is inspired by Λ-kissing in LM with minimal overlap of stent balloon and safety balloon.Similar to Afzal's technique, a balloon has been parked LM-to-LCXas a marker. After stent implantation, kissing balloon is usually appliedespecially if there is a narrow angle between LAD and LCX. Parked safetyballoon could be inflated together with stent for a prophylaxis purpose if possibility of plaque shift is too high. In conclusion, Stent-Λ-Balloon Technique might be used in the treatmentof LAD ostial stenosis which allows precise positioning of a stent, prevents/treatspossible plaque shifting and crushes unnecessary stent over LCX ostium.