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A 52-year-old man presented with chronic coronary syndrome. His cardiovascular risk factors were active smoker and hypertension. He was known to have complex coronary lesions and was referred to our hospital for complex PCI after adamantly refused surgical revascularization. His physical examination was normal.

The laboratory findings were within normal limit. The electrocardiogram showed normal sinus rhythm. The echocardiogram revealed normal left ventricular ejection fraction and global normokinetic. The myocardial perfusion imaging (MPI) revealed induced ischemia in anterior and inferoposterior segments with 10.3% of ischemic burden.

Coronary angiography demonstrated right dominance system, severe left main bifurcation stenosis (Medina 1,1,1). There was severe stenosis at large high Diagonal 1 (D1). The RCA was normal (Figure 1). SYNTAX score 31, EuroScore II 0.5%, STS score 0.36%.

We used 7 Fr EBU guide catheter via right femoral artery. IVUS revealed eccentric fibrotic plaque in LM, LAD and LCx. Initial plan was LM-LAD crossover stenting. LM-LAD was predilated using a 3.0 x 15 mm NCB. Concerning potential compromised of ostial LCX during LM-LAD stenting, LCx was predilated using 3.0 x 15 mm Scoreflex(OrbusNeich®, Hongkong). Unfortunately, ostial LCX was dissected and forced us to switch to 2-stents strategy. After implanting a 3.0 x 34 mm DES at mid LAD, we decided to perform DK-crush technique. A 3.0 x18 mm DES was deployed to 10 atm at LCx with slight protrusion into LM. The stent balloon was pulled slightly proximal and was re-inflated to 18 atm.The protruded LCx stent was crushed by 4.5 x 10 mm NCB. IVUS visualized complete stent crush and non-distal rewire crossing point to LCx. We did 1^st KBI by using 3.5 x 15 mm NCB (LM-LAD) and 3.0 x 15 mm SCB (LM-LCx) sequentially to 18 atm and simultaneously to 12 atm. Following rewiring D1, a 4.0 x 26 mm DES was implanted at ostial LM that overlap proximal part of mid LAD stent. Following POT with 4.5 x 10 mm NCB, we rewired LCx via non-distal cell as confirmed by IVUS. 2^nd KBI and re-POT was done with the same protocol as the first one. IVUS visualized stents underexpansion in both LM-LAD and LCx. Hence, we did 3^rd KBI using the same balloon sequentially to 22 atm and simultaneously to 18 atm. Final IVUS showed no dissection, adequate stent expansion and apposition. Final angiogram showed TIMI 3 flow in LCA.

Preserving the side branch is one of the most important aspects in deciding appropriate approach for bifurcation stenting. Upfront-1-stent strategy should be the first approach in non-complex bifurcation lesion while it should always be layered with other strategy as bailout. In this case, as the LMB lesion turned into a complex situation after lesion preparation that result from significant dissection of ostial side branch, we therefore needed to adapt immediately to the situation by switching to DK-crush technique. We used IVUS to optimize the procedure.