A challenging Case Report : Multiple bifurcation approach in patient with ACS

By Imad Sheiban
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Imad Sheiban


Imad Sheiban1


Pederzoli Hospital / University of Torino, Italy1
Complex PCI - Bifurcation/Left Main Diseases and Intervention

A challenging Case Report : Multiple bifurcation approach in patient with ACS

Imad Sheiban1

Pederzoli Hospital / University of Torino, Italy1

Clinical Information

Patient initials or Identifier Number


Relevant Clinical History and Physical Exam

78 yrs male. Risk factors : Familiarity , Hypertension, dyslipidemiaComorbidities: COPD, mild renal Failure, previous strokeClinical History : 2015 first episode of chest pain on exertionand hypertension . Treated with beta-blockers, ACE inmhibitors and ASA. . No symptoms till 2022.April 2022: admitted to the hospital for prolonged chest pain. At Admission : BP = 145/95 mmHg, HR=68 bpm, O2 saturation 96%. Killip  Class  1 .Shifted to Cath Lab  for coronary angiogarphy 

Relevant Test Results Prior to Catheterization

Blood Tests: Creatinie :  135 umol/l , Glucose : 5,7 mmol/l, Hb : 13,2 g/dL, RBCs : 4,6  106 /uL , WBCs  : 8.5  103  /uL , Platelets : 195  103  /uL, , CRP : 7.7 ng/dlT-Troponine (1 hour) : 75 ng/L T-troponine ( 2 hours) : 174 ng/L CK-MB  : 4,7  ng/mLTotal Choletserol : 5.8  mmol/lLDL cholesterol   : 3.86 mmol/lHDL Cholesterol : 1,21  mmol/lTriglycerides      : 2,2 mmol(l ECG : ST/T depression in nterior wall ( Fig A) ECHO : Anterior Hypokinesia- LVEF = 0.46               

Relevant Catheterization Findings

Coronary angiography :  Distal Left main with  3- vessel disase  Distal left main stenosis involving both LAD and LCX ostium   Medina  1,1,1  confirmed on OCT LAD - 1st diagonal disease  Bifurcation disease  -Medina 1,1,1 -  (  Large  bifurcated diagonal branch with long prosximal lesion )  LCA -OM bifurcation lesion  - Medina  1,0,1 -RCA : long lesion 
Syntax Score = 32Syntax Score II : PCI :    39.3  -  4-yr Mortality 14,3%CABG: 53.1  -  4-yr Mortality  38.7%

Interventional Management

Procedural Step

Heart Team discussion   ( + patients preference ) : :PCI option Plan :  Femoral access- 7F guiding catheter .- Intravascular imaging ( OCT ) to better define  LM and LAD  lesions and to plan accordingly the strategy OCT : significant disease in distal LM ( MLA= 4.4 mm ) diffuse diseasin prox LAD  (MLA 2.9 mm ) , severe lesione at LCX ostium  ( MLA = 2,1 mm) . Strategy : miniCulotte at LAD-1st Dig bifurcation and DK minicrush at distal LM  both realizes with a single stent from LM to LAD.  Stepwise approach : Wiring LAD and Fisrta Diagonale and LCX Predilatation in Diagonal -LAD . HP deployment of Xience stent 2.75x23mm in I diagonale protruding 2 struts ina LAD . POT In LAD - Recrossing the stent with awire to LAD - Stent strut Dilatation with 1-1 balloon. KBI ( LAD-LAD nd LAD - Diag ) and POT  ( Fig C)Predilatation LCX .  Xience Stent 3.0x15 mm on the wire to LCX  with minimal protrusion in LM  and  balloon on LAD wire  in crossover LM-LAD . Stent in LCX depoluyed at HP . Delivery balloon retrieved . Protruded segment of the stent in LM crushed with the balloon already on site. Recrossing proximale the crushed setnt with a wire to    LCX  -  1st  KBI (LM-LAD-LCX) and deployment of Xience  3.5 x 23 mm from LM to LAD completing both miniculotte ( LAD- Diag) and DK cruish ( distal LM) with the same stent. POT in LM- recrossing the stent with a wire to Diag and another to LCX . KBI and POT at LAQD-Diag Bifurcation and 2nd KBI and POT in LM Bif.( Fig D)Final OCT runs : LAD to LM and LCX to LM. Final angio  

Case Summary

My take home message : Complex stenting in bifurcation lesion and particularly in  distal  Lm is challenging .Intravascular imaging is essential to appropriately define distal LM disease and to  plan the most appropriate approach  Operator experience in BL interventions and stepwise approach can help in making  complex stenting simple Intravascular imaging based final  optimization  is always recommended