Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 57-year-old- man admitted to RSUD DR. Soetomo Surabaya because of progressively increasing chest pain for minimal efforts. He had unregulated diabetes for 5 years and was a heavy smoker. This patient hospitalized 1 month ago with inferior myocardial infarction and underwent primary PCI. His blood pressure was 130/80 mmHg, heart rate 90 bpm, and respiratory rate 20 times per minute.
Relevant test results prior to catheterization
The electrocardiogram showed sinus rhythm 67 bpm with inferior old myocardin fraction. A transthoracic echocardiography revealed normal left ventricular (LV) systolic function (Ejection fraction 62%) with normokynesia of segmentalLV.
Relevant catheterization findings
A coronary angiography via right femoral artery approach showed significant stenosis 60% at distal LM with type A subtype A2b trifurcation lesion with modified media classification 1101. it showed diffuse disease from osteal to distal LAD with maximal stenosis up to 80% at ostial-proximal LAD, stenosis 60% at proximal-mid ramus intermediate (RM), and stenosis up to 70% at ostial-proximal nondominant LCX. There was old patent stent at proximal-mid RCA, Syntax score 40.
Trifurcating wires were used to cross LCX (BMW wire), ramus intermediate (BMW wire), and LAD (run through NS hyper coat wire). Using crush technique, predilatation with Across HP balloon 2.5 x 20 mm in the proximal and ostial LAD at 18 atm, pulled out, was placed in the ostial proximal LCX and dilated at 18 atm, then was placed in the distal LM - ostial proximal LAD. In the next step, the first stent was the 2.75 mm x 25 mm Cre-8 DES Stent, deployed into the ostial-proximal LCX at 9 atm as side branch, protruded into LM. Across HP balloon pulled out. The second stent was the 3.5 mm x 24 mm Biomime DES Stent which placed in the LM–ostial–proximal LAD, deployed at 9 atm, post dilated at 16 atm. Saphire balloon II 1.5 x 12 mm was dilated at proximal – mid LAD at 14 atm, followed by Across Hp balloon 2.5 x 20 mm at proximal LAD 10 atm. The stent DES Biomime 2.75 x 48 mm at proximal - mid LAD overlapped with stent above, deployed at 18 atm. We tried to insert the 2.5 mm x 38 mm Cre-8 DES stent inside STO1 and placed to RM, but failed. Predilated with the 2.75 x 25 mm Cre-8 ex-stent balloon 12 atm at proximal - mid RM. Then, the stent DES Cre-8 2.5 x 38 mm inside STO1 catheter placed at proximal - mid intermediate and deployed at 12 atm with mother-and-child method. Triple kissing balloon with Cre-8ex-stent balloon 2.5 x 38 mm at ostial proximal LAD, Mozec balloon 2.0 x 9 mm at proximal-mid intermedius, and, Mozec balloon 2.0 x 9 mm at ostial LCX, dilated at 6 atm. Good final result.
We reported a 57-year-old man with distal LMCA type A subtype A2b trifurcation lesion with modified medina classification 1101. Our strategy was a step-crush technique to treat left main distal trifurcation with additional stenting in ramus intermedius provisionally using modified double guiding catheter mother-and-child techniques. A procedure was closed by a triple kissing balloon with good final result without residual stenosis (TIMI flow grade III).