A 47-year-old gentleman patient was admitted to the hospital due to recurrent chest pain. Angiography showed 80% stenosis in the ostial LMCA. One drug-eluting stent (DES) was implanted from the ostial LMCA to the part of the distal LMCA. An excellent angiographic result was achieved.

Significant left main coronary artery disease (> 50% diameter stenosis) is found in 4-10% of patients who undergo coronary angiography.1 In accordance with the present guidelines on myocardial revascularization of the European Society of Cardiology (ESC), patients with left main coronary artery (LMCA) stenosis are appropriate candidates for coronary artery bypass grafting (CABG) as well as percutaneous coronary intervention (PCI).2 The key factor which determines the treatment strategy is the result presented in the risk stratification scale (SYNTAX score) as well as the localization of the lesion in the left main.3 Another important factor is the presence of single or multi-vessel coronary artery disease.4&5 Immediate PCI is considered in acute coronary syndrome (ACS) patients with or without cardiogenic shock due to left main disease.6&7

A 47-year-old gentleman of Asian origin with a history of recurrent intermittent chest pain treated with a conservative strategy 2 months before was admitted to the hospital due to recurrent chest pain for 7 days. The patient's concomitant diseases were arterial hypertension, diabetes and dyslipidemia. On admission, pulse was 72 bpm (regular) blood pressure was 130/60 mm Hg. His electrocardiogram (ECG) & Echocardiogram (ECHO) had no significant changes.

The coronary angiography showed 80% obstruction in the ostial part of the LMCA (Figure A), free of stenosis in the left anterior descending (LAD) artery (Figure B). Moreover, free of disease of the right coronary artery (RCA) and Left circumflex. As he was a high risk patient, it was discussed in "heart team'' meeting and he was suggested for PCI.



During the procedure, wiring were done in both LAD & LCX. Then the wire in LCX was withdrawn & kept floated in the aorta, which acted as the marker of origin of LMCA. Direct stenting was done with deployment of one DES (Sirolimus-eluting stent). The stent (4.0mm × 09 mm) was implanted into the ostial LMCA. Post-dilatation was performed using a POT technique with a 4.0x06mm NC balloon. The final angiographic result was proper. After a 2-day rehabilitation, the patient was discharged from the hospital, with a double antiplatelet therapy recommendation (clopidogrel 75 mg/day + aspirin 75 mg/day). After 20 days the patient came for a follow-up. All necessary investigations were done & reports were normal.

FIGTURE:

A. Coronary angiogram of LCA showing Ostial LM disease;

B. Coronary angiogram of LCA AP Cranial view;

C. Coronary angiogram of RCA showing no significant disease;

D. Guiding Catheter engaged & given intra coronary GTN;

E. After giving GTN fluoroscopic view shows significant disease;

F. Stent advanced in the coronary with Floating wire technique on Left aorto-ostial lesion;

G. Stent inflation;

H. Post-dilatation of the stent; I. Final angiographic result.

The Pathogenesis of this case is unclear. LMCA intubation was done with diagnostic catheter (JL 6 F), during PCI a guiding catheter (launcher 6F EBU 3.5 SH) was introduced. Iatrogenic LMCA dissection is a complication of PCI. In most cases, this occurs as acute dissections caused by invasive procedures. There are no data concerning LMCA perturbation caused by stenting other coronary arteries and their possible consequences.1 The endothelial cell dysfunction might be the cause of atherosclerosis. As a consequence of it, LMCA ostial stenosis might have developed in this case. Due to CSA and the location of the lesion, PCI was performed with an optimal effect, 

which appeared to be the best solution for the patient. The LMCA ostial stenosis may be the consequence of the previous coronary angiography in other situations. To detect the left main disease, a coronary angiogram is the appropriate tool for diagnosis, which is helpful for long-term prognosis and outcome

In conclusion, Ostial left main PCI can be performed safely in selected patients. The decision to proceed with PCI versus CABG is best made through a multidisciplinary approach consisting of a clinical cardiologist, interventional cardiologist and a cardiac surgeon (Heart team) 9. It entails consideration of the patient’s preferences and expectations, comorbidities, the estimated surgical risk, the complexity of coronary anatomy and the patient’s ability to comply with dual antiplatelet therapy

Due to logistic issues IVUS guided PCI cannot be done.

Nothing to declare

1. Grzegorz M et al. Ostial stenosis of the left main CA as the result of the previous PCI on the left coronary artery, Postępy w Kardiologii Interwencyjnej 2013; 9, 3 (33) 

2. Wijns W, Kolh P, Danchin, et al. Guidelines on myocardial revascularization. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2010;31: 2501–2555. 

3. Apostolidou E, Kalisetti D, Logani S, et al. Myocardial revascularization in patients with left main coronary disease. J Invasive Cardiol 2013; 25: 201–217. 

4. P.R. W, A.TP. N. A novel technique for placement of aorto-ostial coronary stent using goose-neck snare IHJ Cardiovascular Case Reports (CVCR) 5 (2021) 149e152 150. 

5. Stephan W, Philippe K, Fernando A, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Journal of Cardio-Thoracic Surgery (2014) 1–102. 

6. Vaquerizo B, Serra A, Ormiston J, et al. Bench top evaluation and clinical experience with the Szabo technique: new questions for a complex lesion. Cathet Cardiovasc Interv. 2012;79(3):378e389. 

7. Dishmon DA, Elhaddi A, Packard K, Gupta V, Fischell TA. High incidence of inaccurate stent placement in the treatment of coronary aorta-ostial disease. J Invasive Cardiol. 2011;23(8):322e326. 

8. Ostial pro stent positioning system step by step. [Internet] https://cloud.merit. com/catalog/Brochures/402383001-A.pdf. 

9. Mirvat Alasnag, et al. Left Main Coronary Artery Interventions. Interventional Cardiology Review 2019;14(3):2 October 2019.