This is a male patient, 31 years old, admitted due to anterior wall STEMI 1 week prior to admission. He had no hypertension, diabetes, but lead a sedentary life for 10 years, and had acute body weight gain over last 2 years with 167 kg, BMI 49.3. (A) He presented with cardiogenic shock with blood pressure of 70/50 mmHg, heart rate 140 bpm. Extensive ST elevation was noted through leads V1-5, Emergency PCI was performed under ECMO support.

Access: The right FA was occupied with ECMO units. The Left FA was too tortuous to push the catheter to descending aorta. The right radial artery was untouchable. Thus the only approach left was left radial artery.

Angiogram; CAG showed aneurysmal RCA and a LM occlusion at ostium with dissection and thrombus. Surgeon refused CABG (B).

PCI: (B) Through EBU 3.5 & JL4.0 Guiding catheter, it is difficult to advance Runthrough NS wire to cross the dissected LM due to enter into the false lumen. (C) A 6Fr JL 5 GC was exchanged, through which, two Runthrough NS wires were advanced into the distal D1 and LAD. Then D1 and LCX flow were recanalized. (D, E) The LM to LAD was pre-dilation with Ryujin 2.5 × 20 balloon at 16 atm, (F) Stenting to D1 was performed with 2.5 × 24 Partner stent at 14 atm. (G–I) LM-LAD stenting was performed with 3.5 × 29 Partner stent at 14 atm. After recanalization the heart rate was dropped to (120–100 bpm) immediately. Patient was recovered well.

This is a male patient, aged at 47 years with history of DM and hypertension, admitted due to exertional chest pain.

A: CAG showed a distal LM bifurcation lesion involving LAD and LCX (A, H). B: Lesion was pre-dilated with 2.0 × 20 mm balloon. C: A 3.5 × 24 mm Stent and 2.0 × 20 mm balloon were placed at LAD and LCX respectively. Initially, balloon in LCX was dilated. D: Then, the stent in LM-LAD and balloon in LM-LCX were dilated together at 10 atm E: LM-LCX balloon were pulled back. E: The stent was one more dilated with stent balloon at 14 atm. F: The proximal stent was further dialed with 4.0 mm NC Balloon at 14 atm. (POT) G, I: final result.

This is a male patient, aged at 67 years, with history of hyperlipidemia and ex-smoker, admitted due to intermittent chest pain for two years. Angiogram on Sep 26 2013 showed DLM 50 %, o LAD 90 % o LCX 90 % (A). The LM lesion was treated by culottes double stenting technique with 3.5 × 18 mm XienceV at LM-LCX and 3.5 × 18 mm XienceV at LM-LAD (B–D); completed with double kissing (2 NC 3.5 × 12 mm balloon E, F). Angiogram at 14 month post-op showed restenosis at LM-Olad (G). Plaque transferred to LCX after balloon dilatation at LAD and reversely to LAD after balloon dilatation at LCX (H, I). The lesion was further treated with double kissing balloon (two NC balloon 3.5 × 12 mm) and cutting balloon (J, K), Completed by dilatation with 2 Drug eluting balloon (B Brwaun Melsungen Sequent Please 3 × 26 mm) at LAD and LCX respectively (L, M). Follow up at 1 years showing patent left main stent (N.O).

This is 71 y.o. male presented with unstable angina complicated by cardiogenic shock. His euro score was 17 and SYNTAX Score was 34. A 6 Fr. VL 3.5 Guiding catheter (Mach 1, BSC) was used to engage the LM, Two BMW universal II (Abbott Vascular) guidewires were placed to LAD and IM respectively. A 3.0/13 mm Lacrosse NSE (Goodman) balloon was used to dilate LM to LAD lesion. 2.0/15 mm Tazuna (Terumo) was used to dilate at IM, (A–E). A XT-R (ASAHI INTECC) guidewire was used to cross the LCX, later was exchanged with BMW. The LCX was pre-dilated with a 2.0/15 mm TREK (Abbott Vascular) balloon; With a 2.5/15 mm Tazuna (Terumo) placed at IM, a 2.25/12 mm Promus Element (BSC) was deployed at LCX. The stent was later crushed by the 2.5 mm balloon dilatation (E–K). With a A 3.0/15 mm Hiryu (Terumo) (Terumo) placed at LAD, A 2.5/28 mm Promus Element (BSC) stent was deployed at IM, Then the stent was crushed by 3.0 mm balloon;(L–M), Stent: A 3.0/38 mm Promus Element (BSC) Balloon was deployed at LM-LAD (N, O): IM was recrossed with Runthrough wire and dilated 1.25/10 mm Sapphire (OrbusNeich) balloon. Kissing balloon was performed at LAD and LM by 3.0/15 mm Hiryu (Terumo) Balloon at LAD and 2.5/15 mm Emerge (BSC) at LM (P). Then Kissing balloon was performed at IM and LCX with 3.0/15 mm Hiryu (Terumo) at IM and a 1.25/10 mm Sapphire (OrbusNeich) balloon at LCX (Q). Final results presented well.