Webinar 11 | LM Trifurcation-Slides, Dr. Sheiban

Slides, Dr. Sheiban

Pdf Summary

This document presents an expert overview of the challenges and procedural strategies for percutaneous coronary intervention (PCI) in patients with distal left main (LM) trifurcation disease—a complex coronary anatomy involving the left main artery branching into the left anterior descending (LAD), left circumflex (LCX), and ramus intermedius (RI). The author, I. Sheiban, highlights different lesion patterns within LM trifurcations, classified using a modified Medina system as a 4-digit code indicating stenosis presence in the proximal main branch (LM), distal main branch (LAD), and two side branches (LCX and RI).<br /><br />Successful PCI in such cases requires careful pre-procedural planning based on clinical relevance of each branch, plaque distribution, branch angle, and lesion length. A 7F or 8F guiding catheter with triple wiring into all three branches facilitates treatment. Intravascular imaging is highly recommended for lesion assessment and procedural guidance. Lesion preparation with predilatation is essential.<br /><br />The default approach for less complex lesions or those with moderate calcification and limited length is provisional stenting—implanting a single stent in the most critical or diseased branch while wiring and protecting the others. More complex trifurcation lesions involving all three branches with severe calcification may necessitate two or three stent strategies, such as TAP (T and protrusion), reverse TAP, double-kissing crush, or mini-culotte techniques, striving to minimize stent layers and overlap to reduce restenosis risk.<br /><br />The author presents a clinical case of an 85-year-old male with diffuse multivessel disease including severe LM trifurcation involvement, managed successfully through a multi-stent, stepwise PCI approach using reverse TAP and mini-culotte, guided by careful wiring, lesion preparation, and multiple kissing balloon inflations, resulting in optimal luminal areas and good angiographic results.<br /><br />Key takeaways include the complexity of LM trifurcation PCI, the importance of patient and lesion-tailored strategies, efforts to limit stent use, potential use of drug-coated balloons, and consideration of staged or incomplete revascularization in high-risk patients with renal impairment. No single gold standard exists, emphasizing operator experience and adaptability for these challenging interventions.

Keywords

Percutaneous Coronary Intervention

Left Main Trifurcation

Modified Medina Classification

Provisional Stenting

TAP Technique

Reverse TAP

Double-Kissing Crush

Mini-Culotte Stenting

Intravascular Imaging

Lesion Preparation