Case 91: PCI Manual - Left main trifurcation

An octagenarian presented with unstable angina and was found to have a distal left main trifurcation lesion (severe lesion in distal left main, LAD, and ramus) and a lesion in the distal circumflex. Due to 9.25% predicted mortality based on Euroscore II the heart team decided to proceed with PCI with hemodynamic support (wedge pressure was 25 mmHg). After placing an Impella CP device, the left main was engaged with an 8 French EBU 3.75 guide and all 3 vessels (LAD, ramus, circumflex) were wired. After stenting a distal circumflex lesion a 4.5 mm DES was placed in the left main, followed by V-stenting with stents in the LAD and the ramus and POT. There was no significant residual disease in the circumflex as confirmed by FFR. The case was successfully completed without complications.

[@TheNEF11]

Really great case, great result! very educating! Thank you very much!

[@llacielona]

Great job! Thank you for sharing!

[@tirthankarroy2664]

Bravo

[@tom11298]

Great case and perfect approach. I liked the Idea of separating the 3 wires with the towel as you demonstrated. Are you using the same impella access for the Guide catheter? or you using another site.

[@aymantantawy1475]

Beside technical part, planning is of utmost importance (Hemodynamic support, EUROSOCRE, Heart team discussion) that all contributed to success. Ad-hoc PCI for this case would result in failure.

[@qakistan1234]

Thanks for sharing the case. Did you overlap the stents in LAD/ramus with left main stent?

[@user-su4he3ju7t]

Thank You very much for this case. What would Your treatment strategy be, if FFR in LCx was less than 0.8? Maybe TAP on LCx, final trissing and final POT in this situation, if You performed extended-V in left main-LAD-intermediate? Thank You.

[@micger]

What would be your strategy if there was Medina 1,1,1,1 at the beginning

[@wbcjunior]

why used or euroscore II to assess mortality?

[@joaoboscobastos6133]

Which wire did you put the TCE Stent in? In that case, wouldn't it be a double TAP?

[@praveenalane4331]

I’m sorry I didn’t understand ... How could we be sure that the distal left main completely covered after v stenting with lAD and RI ? Or Did you overlap both LAD and RI stents into the distal left main stent ??

[@saighibouaouinamehdi3153]

could we have done a classic v stenting (LAD and ramus) then stent the left main ?

[@tom11298]

saighi bouaouina Mehdi because the risk of dissection of LM would be high (it is diseased distally), That is why covering the LM first was the plan and then going for a V-stenting approach

[@saighibouaouinamehdi3153]

@@tom11298 thanks But in all cases we plan to put a stent in the LM with or without dissection

[@tom11298]

saighi bouaouina Mehdi in case of dissection after a classical v-Stenting it would be technically difficult to place the LM stent having already 2 stents protruding into the MV

[@aymantantawy1475]

@@saighibouaouinamehdi3153 Beside dissection part, If u do V first then you had to stent LM. The Later would compress either one of previous 2 stents.

[@karthiknatarajan892]

What if there is significant pinching of LCX ostium? Or FFR of LCX is positive? What would be next strategy?

[@aymantantawy1475]

As I understood, there is overlapping between V stents and left main stent. So, there are 2 layers of stent at distal LM all around . If CX is physiologically significant, i would rewire through distal cell (in this case, the wire should pass through ramus stent)then Kissing (LCX, Ramus). Another issue is Kissing would shift the new carina made by V stenting towards LAD. Based on IVUS i would do extra step which is Trissing again.