Case 141: PCI Manual - Double DK crush and investment

A patient presented with NSTEMI and was found to have 3-vessel disease with severe lesions in the left main bifurcation, the proximal LAD, proximal circumflex, mid circumflex and first obtuse marginal branch. He was turned down for surgery and referred for complex PCI.
Upon left main engagement there was significant pressure dampening. A workhorse wire was advanced into the circumflex allowing guide disengagement. Initial injection showed slow flow in the mid circumflex, likely due to wire dissection. Attempts to rewire into the circumflex and re-enter using a Stingray balloon failed, but the patient was hemodynamically stable without chest pain or ECG changes. We decided to proceed with stenting the circ/OM1 and distal left main bifurcations using a double DK crush technique.
The OM1 was predilated and stented followed by crushing of the protruding portion of the stent into the circumflex, rewiring and the first kissing balloon inflation. A stent was placed in the proximal circumflex slightly protruding into the left main. This stent was the main vessel stent for the circumflex/OM1 bifurcation and the side branch stent for the left main bifurcation. Before crushing the circumflex stent we used a Sasuke dual lumen microcatheter to wire into the OM1 and performed the 2nd kissing balloon inflation. We then crushed the circumflex stent with a balloon placed from the left main into the LAD and did the 1st kissing balloon inflation for the left main bifurcation. We stented the proximal LAD and then stented from the left main into the LAD. After POT with a 4.0x8 mm balloon in the left main we rewired the circumflex, followed by the 2nd kissing balloon inflation with a nice final result.
We did not do additional attempts for PCI of the circumflex as the patient was chest pain free without ECG changes.