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A 54 year old  male a known case of Type2 diabetes mellitus, Nephropathy (cr 1.9) Systemic hypertension, CAD, TVD, PostPTCA to LAD 2017,H/OAcute coronary syndrome in  september2021, Post PTCA to LCX (2021)   2months later patient presented with Chest pain and breathing difficulty for fewhrs before admission

ONEXAMNINATION:HR104/MIN, BP- 130/70MMHG, CHEST B/L basal crepts (Kilip Class II)Chest b/l clear,CVS s1s1 normal,no murmur or added sounds

Trop I positiveECG-st-t changes in inf leads and v4-v6Echo:LVEF 40%

CAG- left dominant circulationcritical70%left main disease patentLCX LAD stentsDistalLCX diffusely diseased, OM1 disused diseased.

CAG showed left  main critical  75-80%stenosis
Plan of management-PTCA/Stent to Left main Route Rt femoral,7F sheath IABP inserted through lt femoral routeLeft Coronary artery hooked with 7F EBU guide catheter1BMW and 1 runthrough Guidewires crossed across LAD and LCX LCX stent crushed with 2.5x12 and 3x12mm balloon3.5X24mm DES deployed from Left Main to LADPOT done using 4.5x6mm balloonFinal kissing balloon done with 3x12mm balloon in LAD and 2.75x12mm balloon in LCXFinal POT with 4.5x6mm balloon at 16 atmTIMI 3 flow achieved 

ACS patients with significant unprotected LMCA disease represent one of thr most high risk type of CADIn patients with ACS,LMCA targeted PCI is associated with high risk of cardiac death,MI,instent thrombosi,strokeDistal LM bifurcation lesions pose considerable challenges and require unique approaches for optimal resultAn integrated approach that comines pre procedure planning with intracoronary imaging,improves success rates and long term clinical outcomes