A 65-year-old Thai male with hypertension presented to the emergency department with acute chest pain and dyspnea. The ECG revealed anterolateral ST-segment elevation, new right bundle branch block, and atrial fibrillation. The emergency physician activated the primary PCI protocol. Prior to transfer to the cath lab, the patient was intubated using rapid sequence induction, and intravenous furosemide was administered. Aspirin and ticagrelor were loaded for dual antiplatelet therapy.

- Echo: LVEF 26.9%, akinesia at anterior, anterosepal & anteroseptal wall from basal to apical LV, no significant valvular heart disease, no intracardiac mass or thrombus- Serum creatinine 1.28 mg/dL (eGFR 55.4 ml/min/1.73sqm)- Hematocrit 44.4%, Hemoglobin 14.3 g/dL, Platelet 315,000/uL- Prothrombin time 16.4 seconds, INR 1.51- Total cholesterol 256 mg/dL, Triglyceride 171 mg/dL, HDL 34 mg/dL, LDL 175 mg/dL
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PSAX2.mp4

Coronary angiogram (Access site: RRA 6F sheath, Tiger 4.0 5F diagnostic catheter)- LM: Distal stenosis 40-50% (eccentric lesion)- LAD: Total occlusion (TIMI Flow 0) at proximal LAD, suitable for PCI. 70% stenosis at mild LAD & 90% stenosis at first diagonal branch. - LCX: 70% stenosis at proximal LCX, 70% stenosis at first obtuse marginal (OM), 90% steonosis at second OM &  90% steonosis at third OM.- RCA (right dominant): Mild disease.  The RCA supplies collateral vessels to  LAD.
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RCA2.mp4

Access site: RRA 6F sheath, EBU 3.5 6F guiding catheter. IABP was inserted via RFA for hemodynamic support. A BMW guidewire (GW) was advanced into the LAD, & thrombus was aspirated. A Sion GW was then placed in LCX. IVUS guided a provisional strategy from LM  to LAD restoring flow quickly. The lesion was pre-dilated with a 2.0 × 20 mm balloon & a 2.5 × 10 mm scoring balloon. Biomatrix Alpha stents (3.5 × 36 mm & 2.5 × 24 mm) were deployed from the LM to mid LAD & post-dilated. The LCX became jailed, so the T-and-Protrusion technique was initiated as a bailout, & a Biomatrix Alpha 2.5 × 19 mm stent was positioned for TAP. After TAP, acute thrombosis developed at the neocarina of the LM. The patient received adequate heparin, intracoronary eptifibatide, & vasopressors. The procedure was stopped after achieving TIMI 3 flow in LAD & resolution of ST elevation. The patient was transferred to the ICU for intensive antithrombotic therapy. 3 days later, a relook angiogram via the LFA (EBU 3.5 7F) showed total LCX occlusion. IVUS confirmed excessive LCX stent protrusion into LM. Reverse Double Kissing Crush was performed. The protruded LCX stent was crushed with a 4.0 × 12 mm non-compliant balloon, Sion Blue GW was advanced through the proximal strut, & final kissing inflation with proximal optimization was completed. Plaque protrusion at proximal LAD stent was corrected with prolonged NC balloon dilation. Final IVUS & angiography showed good result.



jailed LCX.mp4
Thrombosis after TAP.mp4
Relook CAG.mp4

◆ In high-risk left main bifurcation intervention during STEMI, a provisional stenting strategy may fail when the side branch is significantly compromised.◆ Urgent bailout techniques, though rapid, carry a risk of acute thrombosis, particularly in thrombus-rich lesions.◆ Conversion to a dedicated bifurcation technique (reverse Double Kissing Crush) offers better scaffolding and predictable side-branch access when provisional and TAP strategies fail.◆ Adequate and intensive antithrombotic therapy is essential in thrombotic left main bifurcation lesions before performing definitive stenting.