A new sequential two-stent strategy for treating true distal left main trifurcation lesion

T he incidence of significant left main (LM) coronary artery stenosis identified by coronary angiography was 5%−17.5% in various clinical presentations; about 80% of stenosis involved the LM bifurcation (LMB). Although percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass graft in LM disease with low-to-intermediate anatomical complexity, PCI for LMB lesions remains the most technically challenging for interventional cardiologists with higher rates of acute periprocedural complications and higher risk of long-term major adverse cardiac events in the era of drug-eluting stent (DES). The optimal technique for LMBs remains uncertain, particularly in the case of LM trifurcation (LMT), a specific type of bifurcation lesions with a significant ramus intermedius (RI). In general, initial provisional stenting technique is considered the standard method for simple LMBs on the basis of the criteria in the DEFINITION study, while two stents strategy should be considered for complex LMBs. The true LMT with three or more branches are highly challenging for interventional cardiologists because of the extreme complex anatomical features and poor long-term prognosis. To date, the data for PCI in true LMTs are limited and the optimal strategy remains unknown. From January 2017 to June 2018, eighteen patients with a true distal LMT lesion (Medina type: 1,1,1,1 or 0,1,1,1), reference vessel diameter (RVD) of the left circumflex artery (LCX) > 2.5 mm and RVD of RI ≥ 2 mm at baseline angiography were enrolled in our study. Among these patients, all lesions met the criteria of complex LMBs in the DEFINITION study (LCX ostial stenosis ≥ 70% with a lesion length ≥ 10 mm). Baseline clinical and angiographic characteristics are shown in Table 1. Seven patients (38.9%) were left coronary dominant and fifteen patients (83.3%) without right-to-left collaterals were considered to have unprotected LMT lesions. The mean SYNTAX I and SYNTAX II scores were 29.1 ± 1.9 and 25.9 ± 5.0, respectively. The RVD of LM, left anterior descending artery (LAD), LCX and RI was 4.5 ± 0.5 mm, 3.5 ± 0.3 mm, 2.8 ± 0.3 mm and 2.2 ± 0.2 mm, respectively. Meanwhile, the plaque burdens of distal LM, ostial LAD, LCX and RI were 64.4% ± 7.0%, 74.9% ± 7.8%, 65.1% ± 7.6% and 41.6% ± 10.7%, respectively. All patients were treated with a sequential twostent strategy combined with double-kiss crush (DKcrush) and jailed balloon technique under intravascular ultrasound (IVUS) guidance. Detailed description of the strategy: (1) after wiring to distal LAD, LCX and RI, IVUS was performed for confirmation of each vessel; (2) LAD and LCX were predilated with compliant balloons; (3) LCX stent was implanted protruding minimally into the LM with a balloon placed at ostial of LAD for crush; (4) LCX stent was crushed with a large non-compliant balloon; (5) the LCX was then rewired through a proximal stent cell; (6) first kissing balloon inflation (KBI) was performed after rewiring to LCX; (7) LM-LAD stent was implanted with a jailed semi-inflated balJournal of Geriatric Cardiology