A 75 - year-old male patient presented to us by typical chest pain that started 6 hours before coming to our ER. He has Past history of IHD; DM; HTN; Rheumatoid arthritis and bleeding Peptic ulcer and was admitted 3 years ago by unstable angina for which PCI to LM - LAD  by 2 DES and Ramus by one DES were done under ECMO and mechanical ventilation support (patient refused CABG at that time; EF was 25 % ).


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hs Trop - i 2748.8 pg / ml; CKMB: 15.5 ng/ml. 12 leads ECG revealed sinus rhythm; ST segment depression in leads I ; AVL; and V2 - V6. The patient was loaded with 600 Clopidogrel and 300 mg ASA and transferred to the cath lab.
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Stenting LM 2.avi

Coronary angiography was done through 7Fr. Rt Femoral artery and showed:LM: Atherosclerotic artery that trifurcates to LAD; LCX and Ramus. Diffuse 90 % ISR in the LMLAD: Patent prior deployed stent from osteal to mid LAD with 90 % ISR in the osteal LAD and 70 % ISR in its mid segment.LCX: Atherosclerotic, non - dominant, giving 2 OM branches. Tight lesion in the osteal LCX. RCA: Dominant vessel that had proximal moderate lesion.Ramus: Patent stent in with 50 % ISR. 
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Stenting LCX.avi
Kissing Ramus and LCX.avi

The LM was engaged by EBU 3.5 7 Fr. guiding catheter and a 0.014'' BMW guidewire was advanced to distal Ramus and another 0.014'' Pilot 50 guidewire was advanced to distal LAD. The LM and osteal LAD were dilated using 1.25 X 20 mm, 2.0 X 20 mm balloons up to 16 and 28 ATM respectively; followed by 3.0  X 12 mm and 4.5 X 20 mm NC balloons up to 28 ATM each. After dilatation of the Ramus and its kissing with the LAD; stenting of the LM - LAD done using 4.0 X 12 DES followed by second kissing of LAD and Ramus. After dilatation of the LCX, stenting of the LCX done from proximal to ostium using 2.5 X 15 mm DES which crushed by a 2.75 X 12 mm balloon that was parked in the Ramus. After post dilatation of LCX; A DCB 2.75 X 20 mm was delivered to the Ramus and inflated at its proximal to ostium up to 16 ATM for 90 sec then a kissing balloon was done to Ramus and LCX using the DCB in the Ramus and a 2.5 x 12 NC in the LCX up to 12 ATM. Another kissing was done to the LAD and Ramus using 3.0 x 12 mm balloon to LAD and the previous DCB in Ramus up to 12 ATM; then triple kissing was done using 3.0 X 12 mm ; 2.75 X 20 mm and 2.5 X 12 mm balloons to the LAD; Ramus and LCX respectively and inflated up to 10 ATM. Final POT to the LM was done using 5.0 X 12 mm NC balloon up to 14 ATM. The mid LAD was dilated using NC balloon 3.0 X 12 mm up to 28 ATM; then a DCB 2.75 X 20 mm was delivered to the mid LAD and inflated up to 20 ATM for 90 sec. TIMI III flow achieved and no instant complication. 

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The incidence of ISR is very high, about 10% of all PCI cases. Acute STEMI with heavily calcific LM has a high risk of mortality. The in-hospital mortality rate in patients with STEMI due to unprotected LM coronary artery stenosis remains high and was previously estimated to be at 47.8 % and nowadays 30 – 40%. PCI for Patients with STEMI and unprotected LM treated during night - time in comparison to the day - time are related to higher in - hospital, 30 - day and 12 - month mortality. Successful PCI to LM – LAD – LCX –  Ramus were done for our patient with double bifurcation techniques and triple kissing and discharged home safely after three days without any complication.