Distal Left Main Trifurcation Lesion Treatment Using Simple Cross-over Stent and Triple Kissing Balloon Technique

- Operator : Antonio Colombo

Distal Left Main Trifurcation Lesion Treatment Using Simple Cross-over Stent and Triple Kissing Balloon Technique

- Operators: Antonio Colombo, MD, Chiung-Jen Wu, MD

Case Presentation

A 64 year-old gentleman was admitted with effort chest pain for one month. One year ago, he underwent PCI at pLCX (Cypher 3.0x23mm) in another hospital. Three months ago, he experienced ISR at pLCX stent which was treated by DEB. His coronary risk factors were hypertension and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=64%) without RWMA. Treadmill test and thallium SPECT were not done. Syntax score was 32.

Baseline coronary angiogram

The left coronary angiogram showed diffuse significant stenosis at distal LM trifurcation lesion ( Movie 1). The right coronary angiogram was near normal ( Movie 2).

Procedure

An 8 Fr XB 3.5 with side-hole guiding catheter was engaged into left coronary artery through right femoral approach. Two 0.014 inch BMW wires were placed into the LAD and LCX, respectively. And another 0.014 inch Sion wire was inserted into RI. After wiring, they performed balloon dilatation at LM to pLAD with a Maverick balloon 2.5x15mm (Figure 1). And then, they deployed a Xience Pime stent 3.5x18mm at LM to pLAD (Figure 2). The following kissing balloon was done at LM to pLAD with a Dura star balloon 3.5x15mm and at LM to RI with a Maverick balloon 2.5x15mm (Figure 3). After kissing balloon, they checked LAD FFR value using a pressure wire. Mid LAD FFR value was 0.67. Therefore, they performed additional balloon angioplasty with two drug eluting balloons (a Sequent Please balloon 2.5x30mm at mLAD and a Sequent Please balloon 3.0x30mm at pLAD) (Figure 4, Figure 5). Then, re-checked FFR value was raised up to 0.85. Because intravascular ultrasound evaluation revealed significant ISR in previous stent at pLCX, they performed balloon dilatation at LM to pLCX with a Quantum balloon 3.5x15mm (Figure 6). And then, triple kissing balloon was done at LM to pLAD with a Dura Star balloon 3.5x15mm, at LCX with a Quantum balloon 3.5x15mm, and at RI with a Maverick balloon 2.5x15mm (Figure 7). Post-kissing balloon FFR value at LCX was 0.82. Final angiogram showed that the procedure was successful ( Movie 3).