Mr WKC

51 years old Chinese man, smoker with underlying Diabetes Mellitus and 3 vessels disease (3VD) with left main (LM) disease, had CABG x 2 done in March 2020. Left internal mammary artery (LIMA) was grafted to Left Anterior Descending (LAD) artery and saphenous vein graft (SVG) to obtuse marginal (OM) artery.  Baseline Echocardiography was normal with ejection fraction (EF) 60 %. 2 months after CABG, he presented with angina for 2 weeks. Vital signs were normal. Physical examination was normal.

12-lead electrocardiography (ECG) showed widespread ST depressions with ST elevation at lead aVR and lead V1. Echocardiography showed moderately impaired LV function with EF 37 % and global hypokinesia. Chest X-ray was normal. Troponin T level was markedly raised. Other blood tests, eg. full blood count, renal profile and liver function test were normal. Hence, he was diagnosed as high risk Non-ST Elevation Myocardial Infarction (NSTEMI).

The native vessels remained same as previous findings. He had 3VD with LM disease. SYNTAX score was 38. He had dominant left circumflex (LCx) artery, bifurcation lesion Medina (1, 1, 1) at distal LM, distal LM 60% stenosis, ostial LAD 99 % stenosis, mid - distal LAD 70 - 90 % stenosis, ostial LCx 70 - 80 %, distal LCx 99 % stenosis and chronic total occlusion (CTO) at mid recessive right coronary artery (RCA). LIMA - LAD graft was small and occluded. SVG - OM graft could not be located.
A.avi
D.avi
B.avi

Patient refused redo CABG. We performed upfront 2 stents LM bifurcation PCI with double kissing (DK) crush technique. Intra-aortic balloon pump (IABP) was inserted. Left coronary artery (LCA) was engaged with 7F EBU 3.5 via right radial artery with difficulty due to tortuous subclavian artery. Fielder XT-R wired into LCx and BMW wired into LAD. Sequential pre-dilatation done at proximal - distal LAD and LCx with multiple semi-compliance balloons size 1.5, 2.0, 2.5 and 3.0 mm. Intra-vascular ultrasound (IVUS) showed whole length of LAD was diffusely diseased with heavy plaque burden. Distal LCx was stented with drug eluting stent (DES) XIENCE Xpedition 2.5 x 38 mm, followed by proximal LCx with XIENCE Xpedition 3.0 x 18 mm (overlapped) with small protrusion of proximal stent edge into LM. Proximal stent edge was crushed with Non-compliant (NC) balloon 4.0 mm. LCx was re-wired with Sion Blue. First Kissing Balloon Inflation (KBI) was done with NC balloon 3.0 mm at LCx and 4.0 mm at LAD. Next, mid - distal LAD was stented with XIENCE Xpedition 3.0 x 48 mm, followed by proximal LM – LAD stented with XIENCE Sierra 4.0 mm x 28 mm (overlapped). Post-dilatation was done at proximal - distal LAD with NC balloon 3.0 and 4.0 mm, followed by proximal optimization technique (POT) at distal LM with NC balloon 4.5 mm. LCx was re-wired again with Sion Blue. Second KBI was done with the same balloons and finally re-POT at distal LM. Post stenting IVUS showed stents well expanded and no malapposition.
C.avi
E.avi
F.avi

IABP was removed after procedure. Patient was discharged well after 2 days. Follow up 6 months after PCI patient remained well and asymptomatic. In conclusion, despite CABG offers more benefits in left main coronary artery disease with high SYNTAX score, complex PCI is an option when patient refuses CABG or ill patient is not stable to be transferred for CABG in a centre without on-site cardiothoracic service. The successful rate will be higher if the procedure is well planned and with intra-coronary imaging guidance.