Protected Distal LMCA Crush Stenting

600 mg Clopidogrel, 300 mg Aspirin, Atorvastatin 40 mg, and Heparin 7500 U were given. A 5 Fr sheath was inserted via the left femoral artery in case an IABP was needed. ACT was checked, and heparin administered to have optimal anticoagulation. LMCA was engaged with a 7Fr EBU4 guiding catheter, and floppy guidewires were inserted into the ramus and LCX that were predilated with a Simpass 2.5x15mm balloon (Figure 5, Figure 6). A 2.5x18mm Nobori stent was placed into the LCX, and a Promus Element 3x20mm stent was placed from the LMCA to the ramus. The Nobori stent was withdrawn 3-4mm into the LMCA and inflated at 12atm (Figure 7). The LCX balloon and guidewire were withdrawn, and the ramus stent was inflated at 12atm to crush the stent in the LMCA (Figure 8). When we tried to rewire the LCX with a floppy guidewire, the guidewire kept going under the stent; and the balloon did not follow into the LCX. The stent in the LMCA was post-dilated with a 4x15mm Turquoise balloon for better wall apposition and easier entry into the LCX. The LCX was rewired, and kissing balloon inflations with Simpass 2.5x15mm and Turquoise 4x15mm balloons, both at 10atm, was performed (Figure 9). After kissing balloon inflations and balloon withdrawal, we realized that the ostial part of the LMCA stent was distorted by the guiding catheter (Figure 10). We lost the LCX guidewire position and withdrew the floppy guidwire into the LCX. In order to correct the ostial part of the stent, we inflated a 4.5x15mm Simpass Plus baloon from the LMCA to the ramus at 12atm (Figure 11). Images taken after ballooning showed "orrection"of the stent struts in the LMCA, but the LCX stent showed a new ostial narrowing. Luckily, we rewired the LCX with some difficulty (Figure 12). The LCX ostial struts were postdilated again with a Simpass 2.5x15mm balloon, and the narrowing was corrected (Figure 13, Figure 14).