Tewan Suwanich, Imad Sheiban, et al
A 49-year-old male with a history of prior coronary bypass graft surgery three months before came back with typical anginal chest pain on exertion. His angina was classified as grade III according to the Canadian Cardiovascular Society grading system. The risk factor for coronary artery disease in this patient was smoking. However, he had stopped smoking after the bypass surgery. An exercise stress test showed a positive result with horizontal ST depression in II, III, aVF, V4, V5, and V6 at low workload. His medications included aspirin 325 mg daily, simvastatin 20 mg daily, and atenolol 50 mg daily. Coronary angiography showed a 95% stenosis at the trifurcation of the left main coronary artery (LMCA) involving the ostium of the left anterior descending artery (LAD), the left circumflex artery (LCX), and the ramus intermedius (RI). The angulation between the left main artery and the left circumflex artery was nearly 90 degrees (Figure 1, Moving image 1). The internal mammary artery was diffusely diseased without antegrade flow into the LAD (Figure 2, Moving image 2). The saphenous grafts to the diagonal branch and the posterior descending artery were patent. Graft to the LCX was not found. He declined re-operation. His healthcare payment did not cover rotational atherectomy.
Supplementary data
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Moving image 1. Coronary angiogram showing a 95% stenosis at the trifurcation of LMCA involving the ostium of the LAD, the LCX, and the RI branch with angulation between the LMCA and the LCX of nearly 90 degrees.
Moving image 2. The diffusely diseased internal mammary artery without antegrade flow into the LAD.
Moving image 3. Balloon inflated again in the LAD beyond the lesion and pulled back against the plaque towards the guiding catheter in an attempt to change the angulation between the LMCA and the LCX.
Moving image 4. Balloon inflated again in the RI and pulled back towards the guiding catheter in an attempt to reduce the RI-LCX angle.
Moving image 5. Final angiogram showing TIMI 3 flow in all branches with no dissection demonstrated.