Bifurcation percutaneous coronary intervention of left main
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The default approach in bifurcation percutaneous coronary intervention (PCI) generally involves simple strategies with a single stent or provisional side branch (SB) stenting. Authors previously reported an experimental bifurcation bench model study that showed good effects on obstruction by stent struts at a jailed SB ostium using a proximal balloon edge dilation (PBED) technique in the repetitive proximal optimizing technique (re-POT) sequence compared with conventional SB balloon dilation.

SB dilation with the PBED technique prevented stent deformation induced by SB dilation and eliminated the need for the second POT procedure in the re-POT sequence. In this case report, doctors performed PCI in a left main trunk (LMT) bifurcation lesion using PBED technique and the three-dimensional reconstruction (3D) of optical coherence tomography (OCT) showed excellent acute results after the PCI procedure.

A 67-year-old man with acute coronary syndrome was transferred to our hospital. Emergency coronary angiography (CAG) showed total occlusion of the mid-right coronary artery and primary PCI was performed. One month after successful primary PCI, physiological assessment by fractional flow reserve detected residual ischemia at the distal LMT. Doctors thus decided to perform bifurcation PCI (Medina's classification 1,1,0) under 3D-OCT guidance. CAG showed 75% stenosis at the distal LMT. Using a Telescope guide extension catheter, OCT evaluation of the distal LMT lesion revealed a 4.1-mm2 minimal luminal area of a 23-mm long lesion having a thick cap-fibroatheroma plaque with calcification.

Proximal and distal reference vessel diameters were 4.5 mm and 3.5 mm, respectively, and we implanted a 3.5 mm × 23 mm everolimus-eluting stent from the mid-LMT to the proximal left anterior descending artery lesion, crossing over the left circumflex artery (LCx). After stent implantation, a proximal optimization technique (POT) was performed with a 4.5 mm × 8 mm non-compliant balloon to fully appose the proximal part of the stent in the LMT.

After rewiring to the LCx, no links connecting to a carina and appropriate re-crossing positions of the wire were confirmed using 3D-OCT. SB (LCx) dilation with a 2.5 mm × 6 mm non-compliant balloon using the PBED technique was performed. The procedure for the PBED technique was that the balloon for SB dilation was positioned precisely, with the proximal radiopaque marker lying in the cross-sectional plane of the stent struts at the LCx ostium. After successful SB dilatation using the PBED technique, CAG showed good angiographic results and 3D-OCT revealed good opening of stent cells overlying the SB (LCx) ostium.

Lumen area at the ostium of LCX did not change during the POT-PBED procedures (from 4.5mm2 to 4.4 mm2). OCT demonstrated well-apposed stent struts opposite the LCx. They thus decided not to perform the second POT (re-POT) procedure because incomplete stent apposition was not observed at either the proximal stent edge of the LMT or the side opposite the LCx on OCT.