A 60-year-old female with chief complaint of typical chest pain and shortness of breath on exertion was admitted to hospital to undergo PCI. She had risk factors of Hypertension and Type 2 Diabetes Mellitus on routine medication. She was moderately build and her physical examinations were normal prior to procedure
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ECG: Sinus rhytm, 82 bpm with poor R wave progression V1-V3. Vital sign and laboratory findings prior to PCI procedure were normal

Left Main stem was long and had subtotal stenosis, LAD had ostial subtotal stenosis and CTO at mid part with distal collateral filling from RCA, both LCx and RIM had subtotal stenosis also in ostial parts, while RCA is dominant and had no significant stenosis
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XB 3.5/7F was used to cannulate LCA and JR 3.5/6F to cannulate RCA. Runthrough NS Floppy was placed at RIM, Fielder XT-A with backup of Finecross microcatheter was placed at distal LCx. Predilation at LM-LCx with Semi-compliant (SC) balloon 2.0x15 mm. Wire at LCx was exchanged with Runthrough NS Floppy. Fielder XT-A with backup microcatheter successfully crossed CTO and placed at distal LAD. Exchange wire with Runthrough NS Floppy at distal LAD. Predilation with SC balloon 2.0x15 mm from distal LAD to LM and with Scoring balloon 3.0 x 15 mm. Ostial RIM was dilated using SC balloon 2.0x15 mm.  DES 3.5x38 mm was implanted at mid LM to mid LAD, followed by Proximal Optimization Therapy (POT) with Non-compliant (NC) balloon 4.5x8 mm. DES 3.0x30 mm implanted at mid-distal LAD overlapping with previous stent. Angiographic showed LCx was compromised. Rewire LCx with Runthrough NS Floppy placed at OM1. SC balloon 2.0x15 mm was used to open strut. Kissing Balloon Inflation (KBI) with exstent balloons 3.5x38 mm in LM-LAD and  3.0x30 mm in LM-LCx. Angiographic evaluation showed dissection at ostial LCx. Decision was to bailout by implanting another stent at LCx using T-and-Protrusion (TAP). DES 3.0x18 mm was implanted at ostial LCx, a bit protruding to the LM. KBI using exstent balloons 3.5x38 mm in LM-LAD and  3.0x30 mm in LM-LCx. POT using NC Sapphire II 4.5 x 8 mm. Final angiographic showed good result
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Tackling LM Bifurcation is always challenging, especially when paired with additional tough lesion such as CTO. While provisional LM-LAD stenting was initially planned, further ongoing events during procedure eventually necessitate two stents strategy. In this case, due to anatomical characteristic, TAP technique was implemented. Provisional stenting is usually the safest and best approach but we must always be ready to bailout with two stents strategy.