487 LEFT MAIN TRIFURCATION RESTENOSIS: A COMBINED STRATEGY FOR A COMPLEX ANATOMICAL SCENARIO


 Unprotected left main trifurcations (ULMT) are highly challenging lesions for the interventionalist. There is still no evidence on the best revascularization strategy, and the risk of short-term procedural complications and long-term adverse outcomes remains high.
 We report the case of a 62-years-old with multiple risk factors and a high bleeding risk attributable to severe pancytopenia. Due to an episode of unstable angina, he underwent coronary angiography showing a left main stem (LM) trifurcation with critical ostial left anterior descending (LAD) stenosis, and a proximal LAD sub-occlusive lesion extending to the ostium of the first diagonal (D1) Percutaneous coronary intervention (PCI) consisted of intravascular ultrasound (IVUS)-guided deployment of two drug-eluting stents (DES) from LM to mid-LAD.
 One year later he was admitted for chest pain relapse. Coronary angiogram demonstrated critical in-stent restenosis at the proximal LAD and sub-occlusions of ostial ramus intermediate (RI) and ostial circumflex (Cx) (Figure 1).
 Re-do PCI consisted of multiple pre-dilations and deployment of a DES on proximal-mid LAD within the previous stent, with two sequential triple kissing inflations on LAD-RI-Cx (Figure 2). Angioplasty on RI and Cx was accomplished with two drug-coated balloons (DCBs) kissing inflation, followed by final triple kissing, with an optimal angiographic result (Figure 3).
 In our opinion, the combined use of DCBs and main branch stenting, further optimized by multiple triple kissing balloons, seems to be the most harmonious approach to treat such complex coronary lesions, where the use of multiple stenting strategies might be an overly cumbersome strategy, especially when an intrinsic bleeding risk makes long or powerful anti-thrombotic protocols not feasible.