Mr. WS

A  61 yo male patient with HT, DM, ex-smokermanifested with APS CCS II. History of PCI with 1 DES at the prox-mid LAD in 2019.Physical examination was normal. Resting ECG showed sinus rhythm withoutabnormal ST-T changes. Echocardiography result was unremarkable(LVEF 56%). The left coronary angiogram showed significant stenosis at distalLM, ostial LAD and ostial LCx (Medina classification 1,1,1). There were multiplesignificant stenosis in LCx and all of branches. Patient refused CABG.

A 7 Fr sheath through right femoral artery access was inserted. LCA wasengaged with a 3.5/7F XB guiding catheter. A Floppy guide wire (GW) was insertedto LCx. We pre-dilated  LCx using scoringballoon 2.5 x10 mm 12 atm at distal, and up to 16 at ostial LCx-LM. Beforestenting distal LCx we put second GW at LAD to protect OM3. A 2.5 x 38 mm DES wasthen inflated up to 13 atm at distal LCx. Considering many OMbranches with significant ostial stenosis that may lost if we do stenting at prox-ostialLCx and potential future PCI to LCx we decided to use DCB to treat thatstenosis. DCB 2.50 x 30 mm up to 17 atm was then inflated for 45” at mid LCx-LM. No dissection nor significant recoilwas seen on evaluation. We proceeded to perform PCI for the LM-LAD. Predilationat LM-LAD was done with 2.5 x 10 mm scoring balloon at 18 atm. A 3.0 x 28 mm DESwas then successfully deployed at prox LAD-LM at17 atm, followed by POT at LM-LAD using NC balloon 4.0 x12 mm,18 atm. GW at LAD was recrossed through distal stent strut at ostial, LCxfollowed by predilated ostial LCx with 2.0 x 10 mm then with NC 2.75x12 mmballoon at 14 atm and finalized with KBT using NC balloon 4.0 x12 mm at LM-LAD up to 10 atm. Final POT at LM-LAD with NC balloon 4.0x12 mmup to 22 atm. No residual stenosis at LM-LAD and 20% at ostial LCx.
DEB AND DES IN LCX.avi
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The advent of DCB provides a novel therapeutic strategy for bifurcation lesion by reducing the risk of restenosis due to delivering cytotatic drug thus reducing neointimal hyperplasia. One stent strategycombine with DCB for SB.seem to be a rationale strategy in true LM bifurcation stenosiswhere further PCI to the LCx is potentially needed in the future.