Mr. Yip, a 60-year-old smoker, with a history of hyperlipidemia and cerebrovascular accident defaulted follow-up, presented to the AED department on 29th September 2024 for central chest pain 1 week ago. Vital signs were stable, with blood pressure 156/100mmHg, pulse 81 beats per minute, O2 saturation of 97% on room air. Physical examination showed clear chest, dual heart sound without murmur and no ankle edema. 

ECG showed sinus rhythm with Q wave and ST-segment elevation over lead V1-V3. Chest X-ray showed no consolidation. Highly sensitive troponin I was elevated to 5120ng/L and creatine kinase was elevated to 331U/L. LDL was 3.8mmol/L. HbA1c was 13.9%. Bedside echocardiography showed LVEF 40% with hypokinesia over LAD territory, without significant valvular lesions. 

Coronary angiogram was done using 6Fr TIGII catheter. It revealed a chronic total occlusion of the proximal-to-mid RCA. The left system revealed a left main bifurcation lesion, with a Medina type 1,1,1. There was a 60% stenosis over distal LM. LAD was diffusely diseased, with ostial-proximal LAD 80% stenosis, mid LAD 99% stenosis, followed by distal LAD 70% stenosis. LCx revealed ostial LCx 80% stenosis with a chronic total occlusion at very distal LCx. OM branch was big, with 80% stenosis. 

PCI was performed using 6Fr JL4 guide catheter. A guide wire was used to cross LAD lesion. OCT was performed. Proximal to distal LAD was pre-dilated with 2.0 x 15mm compliant balloon, followed by 2.25 x 15mm NC balloon. A drug-eluted stent 2.25 x 38mm was deployed to mid to distal LAD, and another drug-eluted stent 3.0 x 38mm was deployed to proximal to mid LAD. Distal LAD stent was post-dilated with 2.5 x 15mm NC balloon, and proximal to mid LAD stent was post-dilated with 3.0 x 15mm NC balloon. 
Another guidewire was used to cross OM lesion. OCT was performed. Stenting to LM-LAD/LCx was planned to be done by mini-crush technique. Ostial LCx and OM were pre-dilated with 2.25 x 20mm compliant balloon and 2.5 x 12mm NC balloon. A drug-eluted stent 2.25 x 38mm was deployed to distal left main to OM, followed by post-dilatation with 2.5 x 8mm NC balloon. A 3.5 x 12mm NC balloon was delivered to LAD and inflated to crush ostial LCx stent. Another 3.5 x 18mm drug-eluted stent was deployed to LM-pLAD. POT to LMS was performed with a 4.0 x 8mm NC balloon. OM branch was recrossed by guide wire. POBA to ostial LCx was done by a 1.5 x 15mm NC balloon. Kissing inflation to LMS/LAD and LMS/LCX was performed by 3.5 x 12mm NC balloon and 2.5 x 12mm NC balloon respectively. Good angiographic and OCT results were obtained. 

This case demonstrated successful bifurcation stenting via Mini-crush technique to LM/LAD/LCx in a patient with anterior myocardial infarction under OCT guidance. This approach minimizes stent protrusion into the left main artery, reducing the risk of complications such as in-stent restenosis at LCx ostium.