1. PCI in Left Main Coronary Bifurcation Disease -Step Mini Crush
TianJin Chest Hospital
Wei Wang Hantao Jiang

2. Case Information
Feng XX Male 55Y
Chief Complaint：Intermittent Chest Pain for 5 years，aggravate 3 days。
Risks factors : Hypertension for 5years，smoking for 20y and quit smoking10y。 Intermittent Alcohol intake 。

3. Decreased diastolic function LAB：TG 5.19 TC 1.88 HDL 0.97 LDL 3.45
Case Information
PE： HR 56 bpm，BP 160/90mmHg
UCG： LA32mm LV54mm LVEF 62%
Decreased diastolic function
LAB：TG TC
HDL LDL 3.45

4. CAG
75%Stenosis in LMd , 70%-80% stenosis inLADpm, 70% stenosis in LCXp SYNTAX SCORE 28

5. IVUS MLD 2.03mm MLA 4.41mm2 PB 77% IN LM
MLD 1.78mm MLA 2.93mm2 PB 72% inLAD
Pull back from LAD

6. IVUS
MLD1.76mm MLA3.64mm2PB 65% in LCX

7. PCI Equipment Procedure Approach ： TFA 7F sheath
Guiding Catheter ： 6F EBU3.75
Guide wires ： LAD– Runthrough
LCX– Whispher
Baloon Catheter ：2.5*20mm(Sprinter-Legend)
2.0*15mm(Sprinter-Legend)
3.0*12mm(NC Sprinter)
4.5*8mm(NC Voyager)
Stent： LM--4.0*23mm(Firebird2)
LAD--3.0*29mm(Firebird2)
LCX—3.0*13mm(Firebird2)

8. PCI
3.0*29mm Firebird2 Stent deployment in LADp to middle ,after predilatation in LADm and LMd

9. PCI
predilatation in LCXp and LADp, 3.0*13mmFirebird2 stent deployment in LCXp to LMd

10. PCI
Inflate the baloon in LM, and crush the stent protruded into LM from LCXp

11. PCI
accurate position of ostial LM stent

12. PCI
4.0*23mm Firebird2 stent deployed from LADm to the ostium of LM

13. PCI
Rewire LCX，post dilate LADp to ostial LM and LCXp with 4.5*8mm and 3.0*12mm NC baloon separately ，final kisssing

14. IVUS
IVUS to check stent apposition from LADm to LM

15. IVUS
Check stent apposition from LCX to LM

16. COMMENT PCI One or Two Stents IVUS Pre OR Post
distal LMCA bifurcation Medina 1,1,1 SYNTAX SCORE 28
CABG or PCI
PCI One or Two Stents
IVUS Pre OR Post

17. Indications for CABG vs PCI in patients suitable for both procedures
CAD subset
CABG favored
PCI favored
1- or 2-vessel disease, nonproximal LAD
IIb C
I C
1- or 2-vessel disease, proximal LAD
I A
IIa B
3-vessel disease, simple lesions, full revascularization achievable with PCI, SYNTAX score <22
3-vessel disease, complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22
III A
Left main (isolated or 1-vessel disease ostium/shaft)
Left main (isolated or 1-vessel disease distal bifurcation)
IIb B
Left main plus 2- or 3-vessel disease, SYNTAX score <32
Left main plus 2- or 3-vessel disease, SYNTAX score >33
III B
LAD=left anterior descending coronary artery
Chinese Journal Cardiology,April 2012,Vol. 40 No. 4 17

27. IVUS: LM stenting Always IVUS
PRE FOR intermediate lesions
FOR Sizing and procedural planning
To assess ostial LAD and LCX
To determine when(and howmuch)to debulking
POST IVUS Criteria for optimal stent expansion
-LMCA MSA ≥8.5mm
-LADo or p MSA ≥6.5mm
-LCXo or p MSA ≥5.5mm(≥4.0mm if not stented)
-no plaque burden ＞50% at a stent edge and no major edge dissection.If either are present ,stent it!
Acute malapposition is not importmant :Don’t chase it!
BIGGER IS BETTER------even with DES

28. THANK YOU