Case 126: PCI Manual - Trifurcation left main PCI

A patient with severe, heavily calcified left main lesion was referred for PCI after being turned down for coronary artery bypass graft surgery. She had an ejection fraction of 40-45%. Pulmonary capillary wedge pressure was 18 mmHg. A decision was made to use prophylactic hemodynamic support with an Impella CP device. Insertion of the 14 French Impella sheath caused cessation of antegrade flow through the right common femoral artery. The Impella CP device was inserted, followed by removal of the peel away sheath and insertion of the repositioning sheath, which restored antegrade flow to the limb. After wiring the LAD, ramus and circumflex the left main was predilated and imaged using IVUS that showed non-circumferential calcification. The left main was stented from the ostium to the LAD jailing the ramus and circumflex, which did not develop any significant stenoses. After postdilation (including inflation with a 4.5 mm Ostial Flash balloon) a nice result was achieved as confirmed by IVUS. The Impella was removed and hemostasis was achieved (two Perclose sutures had been placed at the beginning of the case).

[@shangz0216]

Thanks for the educative case sharing.

[@ahmedsabbar9049]

Bravo, a fabulous work.

[@micger]

What is your stenting strategy if both LCx and Ramus are compromised and balloon dilatations didn't work?

[@farukakturk5388]

Sir there seems to be a significant lesion at LCx will you consider to stent it as well?