The Critical Role of Imaging in Managing Complex PCI: A Case Report

Abstract

Background: Left Main Stem (LMS) disease presents significant challenges in interventional cardiology, particularly when the severity of lesions is ambiguous. Accurate assessment is crucial for determining appropriate treatment strategies.

Case Presentation: A 45-year-old male presented to a tertiary care hospital with post-myocardial infarction (MI) angina, five days after being thrombolyzed at a secondary care facility. At presentation, he was clinically stable, with normal baseline investigations. An echocardiogram revealed an ejection fraction (EF) of 35% and anterior wall hypokinesia. Coronary angiography demonstrated severe ostial stenosis of the left main stem (LMS) and subtotal occlusion of the left anterior descending (LAD) artery, persisting even after intracoronary nitrate administration.

Results: Initially planned for PCI of the LMS to the LAD or potential LMS bifurcation stenting, the patient underwent an intravascular ultrasound (IVUS) study three weeks later, which clarified the situation. Contrary to earlier expectations, the IVUS revealed no significant LMS disease. This unexpected finding suggested that the initial pressure damping during angiography was likely due to a thrombotic plaque and superimposed spasm at the LMS ostium. The procedure was performed using a 7F guiding catheter with planned intra-aortic balloon pump (IABP) support, but it ultimately resulted in a simpler PCI of the LAD with ostial coverage.

Conclusion: This case illustrates the critical role of IVUS in managing LMS disease and highlights how advanced imaging can alter treatment strategies. The ability to differentiate between significant and non-significant LMS lesions led to a less complex intervention than initially anticipated, contributing to an excellent post-procedural outcome for the patient.