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Relevant clinical history and physical exam
The 74-year-old man denied underlying disease. He presented with intermittent exertional chest tightness for four days. He visited emergent department due to persisted crescendo chest pain and ACS diagnosed. Physical examination showed normal heart size, normal S1, S2 without murmur and bilateral clear breathing sound.
Relevant test results prior to catheterization
Lab: Hb 13.9 g/dL, Cr 1.0 mg/dL, CK 125U/L, CK-MB 6.28 ng/mL, Troponin I 2.37 ng/mL, T-CHO 158 mg/dL, TG 49 mg/dL, LDL-C 108 mg/dL, HDL-C 46 mg/dL, HbA1C 5.9%
ECG showed NSR, biphasic T over V2-V5 and TWI over inferior leads.
Relevant catheterization findings
LM: Distal 20% stenosis
LAD: Proximal 70% stenosis, mid functionaltotal occlusion
LCX: Patent, collateral to distal LAD
RCA: Proximal 80% stenosis, mid diffusestenosis up to 70%
After engaged left coronary artery with guiding catheter EBU 3.5, Fielder FC wire was wired to distal LAD and Sion wire was wired to distal LCX. After pre-dilatation, one BRS (Abbott BVS 2.5 x 28 mm) was deployed to distal LAD, one BRS (Abbott BVS 3 x 28 mm) was deployed to mid LAD, and the other BRS (Abbott BVS 3.5 x 23 mm) was deployed to proximal LAD, at 10 atm for 60 seconds sequentially. Post-dilatation performed. However, angiography showed LCX ostium compromised, which was suspected due to plaque shift. Besides, the ostium of a diagonal branch was also pinched. After rewiring into a diagonal branch, balloon angioplasty was performed to diagonal ostium with Orbus Neich Sapphire 2 x 15 at 10 atm. The IVUS image of LCX and LAD checked. IVUS showed that the LAD ostium was not covered by the stent, and there was significant stenosis at the LCX ostium. So another BRS (Abbott BVS 3 x 18 mm) was deployed to proximal LCX, following by post-dilatation. A DES (Abbott Xience Xpedition 3.5 x 15 mm) deployed from distal LAD to LAD. Post-dilatation to LM stent with Abbott NC TREK 4 x 8 mm at 14 atm and kissing balloon technique were smoothly performed. The final angiography showed good result. One month later, the patient admitted for RCA intervention. The previous stents were checked by OCT. The OCT revealed good stent opposition and expansion of LM-LAD, LAD, and LCX.
There are few experiences regarding BRS for LM disease. Crush or mini-crush techniques in BRS stenting previously considered contraindicated. We presented a case with successfully hybrid mini-crush procedure with DES and BRS which, resulted in well coverage of lesions without damages of BRS structures. Carefully managing LM disease with BRS plus kissing balloon techniques, hybrid stenting or even crush techniques is effective for bifurcation lesions.