SB

The patient is a 38-year-old male without any relevant risk factors. He underwent difficult primary PCI on LAD in another hospital due to acute anterior ST- segment elevation myocardial infarction on May 20th, 2021. The patient complained from dyspnea on exertion and he was referred to our hospital for angiography and IVUS assessment.Physical examination was unremarkable. 

Electrocardiogram showed Q wave in anterior leads. Laboratory findings were in normal range. Previous angiography showed total thrombotic occlusion of LAD with shifting into the left main and circumflex arteries. At that time, Balloon angioplasty, mechanical thromboaspiration, intracoronary administration of GP IIb/IIIa and stenting were done for him.
Primary PCI.mp4

The patient was scheduled for control coronary angiography and IVUS study in our hospital. In coronary angiography, LAD stent protruded into the Left main and LCX osmium was totally covered by the stent strut. IVUS confirmed this too.

New angio.mp4

We decided to perform IVUS assessment of the previously implanted stent. Wiring of LAD was done carefully. IVUS showed good apposition and expansion of distal stent and malapposition some areas of the mid portion. LAD stent protruded into the left main and LCX osmium was totally covered by stent strut. Sion blue guide wire was passed into the LCX from distal strut and pre dilation and kissing balloon inflation were done. Then a 4 x13 drug eluting stent implanted in left main toward LAD and afterwards POT was performed. In the next stage, after re-wiring of LCX, second kissing and final POT were done.IVUS revealed good apposition and expansion of LAD and Left main stents without any dissection. 
Procedural Step.mp4

Ostial stenting can be very challenging in coronary intervention and directly depends on bifurcation angle.Precise just ostial implantation of stent is usually difficult.in many cases, stent crossing is mandatory for a better outcome.Intracoronary imaging is necessary for complex coronary intervention.