Dr Antonio Montefusco, from Città della Salute e della Scienza Hospital, (Turin, Italy) shares a case of 51 year-old man who underwent primary percutaneous coronary intervention for STEMI. Three drug-eluting stents (DES) were implanted on the proximal-mid left anterior descending (LAD) coronary artery in bifurcation with the first diagonal branch with TAP technique.

Residual stenosis of intermediate branch (IB) and circumflex (Cx) coronary arteries, originating as a trifurcation from the left main (LM), were treated in a staged procedure with implantation of DES in ostial lesions, without protrusion in the LM.

Two days later, the patient reported angina at rest. A de-novo critical stenosis of the ostial LAD, caused by plaque shift, was found and stenting with involvement of the LM was deemed necessary. The large diameter gap between LM and LAD, assessed by IVUS, posed critical issues in the choice of the stent diameter. To overcome this limitation, a self-apposing, balloon-delivered sirolimus-eluting stent (3.5-4-.5 mm x 22 mm Xposition S®, Stentys, France) was positioned in the LM-LAD axis showing excellent adaptation to the marked tapering of the vessel, as confirmed by the “stent boost” and IVUS imaging. Stent crossing and final “trissing” balloon inflation was easily performed on the LM-LAD-IB-Cx trifurcation, with a very satisfactory angiographic result.

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