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CASE20191107_001
CORONARY - Bifurcation/Left Main Diseases and Intervention
The Decision at the Crossroad: Left Main - Left Anterior Descending Artery Percutaneous Intervention
Shathiskumar Al Govindaraju Shathiskumar Al Govindaraju1, Asri Ranga2, Prabesh Neupane3, Hameeth Shah Abdul Wahid4
Manipal Hospital, Malaysia1, Sultan Idris Shah Serdang Hospital, Malaysia2, Shahid Dharmabhakta National Transplant Centre, Nepal3, Hospital Raja Permaisuri Bainun, Malaysia4,
[Clinical Information]
- Patient initials or identifier number:
SD02620
-Relevant clinical history and physical exam:
61years old Chinese gentleman admitted for typical chest pain for 2 days. He is a known case of diabetes mellitus, hypertension, dyslipidemia and gout. He has ischemic heart disease and percutaneous intervention to his left anterior descending artery has been done 10 years ago. Vitals signs were stable.
-Relevant test results prior to catheterization:
His ECG showed Q waves in inferior leads and poor R wave progression in chest leads. Echocardiogram showed ejection fraction of 48% and region wall motions at inferiror and lateral walls of left ventricle. The left ventricle was slightly dilated and other chambers were normal. The blood investigations showed raised Troponin I. Other blood results were unremarkable.
- Relevant catheterization findings:
The left main had distal 80% disease, the left anterior descending artery had ostial 80% stenosis and diffuse in-stent restenosis of previous stent the spans from proximal to mid vessel. The Left circumflex had ostial 70% stenosis and proximal to mid vessel moderate to severe disease. The right coronary artery was dominant, had mid to distal vessel mild disease.
[Interventional Management]
- Procedural step:
IVUS guided PCI done to left main-LAD and circumflex radial approach. EBU 3.0 7f guide. Circumflex lesion prepared with 2.5mm x 15mm semi-compliant balloon and 3.0mm x 13mm scoring balloon. Stented circumflex with DES 3.5mm x 15mm balloon. Circumflex stent crushed with 4.0 balloon with left main-LAD. Circumflex rewired and struts opened with 2.0mm x 10mm and 3.0mm x 12mm balloon. First kissing done. Left main-LAD stented with 3.5mm x 34mm DES. First POT done with 4.0mm x 15mm balloon in left main-LAD. Circumflex rewired and second kissing done with 3.0mm x 12mm in circumflex and 4.0mm x 15mm in left main-LAD. Second POT done. The previous stent with ISR treated with Drug Eluting Balloon with 3.0mm x 25mm. IVUS showed good stent opposition and no dissection.


- Case Summary:
The complex bifurcation of Left main, LAd and circumflex with medina 0:1:1 of treated successfully with Double Kissing Crush bifurcation stenting technique and showed good IVUS result. No dissection or perforation seen. No significant ECG or hemodynamic changes happened during procedure. Patient discharged with dual antiplatelet therapy the next day. 
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