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Unprotected Distal Left Main Trifurcation Lesion Treated with "TAP (T-Stenting and Small Protrusion)" Technique
- Operators :Seung-Jung Park, MD, Young-Hak Kim, MD, Duk-Woo Park, MD
Clinical presentation
A 70-year old man was admitted due to effort-related chest pain for 2 months. His coronary risk factors were hypertension, diabetes, and smoking. The echocardiography showed normal left ventricular function (EF=60) without regional wall motion abnormality.
Baseline coronary angiogram

1. Left coronary angiogram showed very tight luminal narrowing of ostium and distal trifurcation of LMCA and diffuse stenosis of ostium to proximal left anterior descending artery (LAD) and ostium to proximal left circumflex artery (LCX). (Figure 1, Figure 2)

2. Right coronary angiogram showed normal finding.

Procedure
An 8F sheath was inserted through the right femoral artery, and the left coronary was engaged with 8F JL 3.5 guiding catheter. Prophylactic IABP was inserted through left femoral artery. A 0.014 inch BMW guidewire was inserted into LCX and a 0.014 inch Soft guidewire was inserted into LAD. At first, initial balloon dilation was performed with a 2.520mm Black Hawk balloon up to 16atm (2.77mm) for LAD and 18atm (2.82mm) for LCX. Intravascular ultrasound (IVUS) evaluation revealed a heavy plaque burden and circular superficial calcification from LAD and LCX to ostium of LMCA. The LAD and LMCA were predilated with a 3.020mm Ryujin up to 16 atm. (Figure 3, Figure 4, Figure 5) A 3.523mm Cypher stent was deployed at the proximal LAD and another 3.518mm Cypher stent was deployed from LAD ostium to LMCA. (Figure 6, Figure 7) Then, a 0.014 inch Choice PT guidewire was re-inserted into LCX. The LCX was predilated with a 2.520mm Apollo balloon up to 14atm (2.74mm) and a 2.7518mm Cypher stent was deployed with minimal protrusion of proximal stent strut into main branch. (Figure 8) Final kissing balloon dilation was performed with a 2.520mm Apollo balloon for LCX to LMCA and a 3.520mm Pleon balloon for LAD to LMCA. (Figure 9, Figure 10) Post-stenting IVUS showed minimal new carina at distal LMCA (LAD to LMCA; Figure 11 and LCX to LMCA; Figure 12) without stent in-apposition. Final angiogram showed excellent results without residual narrowing, dissection, or any side-branch jail. (Figure 13, Figure 14)
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