February 19, 2026

Back to Operating Room on Post-Procedure Day 3

A Complex Left Main PCI Case by Dr. A. Sreenivas Kumar

Apollo Hospitals, Hyderabad

When the Healer Becomes the Patient

In interventional cardiology, few diagnoses create as much concern as Left Main Coronary Artery disease. It is often referred to as the “artery of life” because it supplies nearly two-thirds of the myocardium through its bifurcation into the Left Anterior Descending (LAD) and Left Circumflex (LCX) arteries.

Now imagine this diagnosis in:

A 55-year-old individual
A practicing laparoscopic surgeon
An active professional who spends long hours inside the operating theatre

This is the story of a highly active surgeon who presented with new-onset angina and dyspnea, was diagnosed with significant Left Main bifurcation stenosis, and underwent a meticulously planned OCT-guided complex PCI using a 2-stent bifurcation strategy.

What makes this case extraordinary is not only the technical precision involved — but the outcome.

The patient was back in his own operating theatre on Post-Procedure Day 3.

Patient Profile and Clinical Background

Demographics

Age: 55 years
Occupation: Active laparoscopic surgeon
Comorbidities:
- Hypertension
- Dyslipidemia

Presenting Complaints

Recent onset angina
Progressive dyspnea on exertion

Initial Evaluation

Interestingly:

ECG – Normal
Echocardiogram – Normal

This highlights a critical clinical teaching point:
Normal ECG and Echo do not rule out significant coronary artery disease.

Coronary CTA Findings

Significant Left Main stenosis
Proximal LAD involvement

Given the anatomical location and severity, coronary artery bypass grafting (CABG) is traditionally considered.

However, the patient preferred to avoid surgery and traveled from Bengaluru to Hyderabad seeking an advanced PCI solution under Dr. A. Sreenivas Kumar at Apollo Hospitals.

Understanding Left Main Bifurcation Disease

The Left Main artery divides into:

LAD – supplies anterior wall and septum
LCX – supplies lateral wall

Significant disease here threatens a large myocardial territory.

Bifurcation lesions are complex because:

Two vessels are involved
Stent placement must maintain patency in both branches
Incorrect technique can lead to side-branch compromise
Long-term restenosis risk is higher

Therefore, these cases demand:

Precise planning
Advanced imaging guidance
Expertise in bifurcation stenting techniques
Perfect procedural execution

Why OCT Guidance Was Critical

Optical Coherence Tomography (OCT) provides ultra-high resolution intravascular imaging.

Advantages include:

Accurate measurement of vessel diameter
Detailed plaque morphology assessment
Identification of calcification
Optimization of stent expansion
Detection of malapposition or edge dissection

In complex Left Main bifurcation disease, OCT significantly improves procedural precision and long-term outcomes.

Procedural Strategy: Step-by-Step Technical Execution

This was not a routine angioplasty. It required a structured, multi-stage strategy.

1. Baseline Angiography and Wiring

Diagnostic angiography confirmed:

Severe Left Main bifurcation lesion
Involvement of both LAD and LCX

Both branches were wired carefully to preserve access.

Baseline angiogram demonstrating Left Main bifurcation stenosis.

This video should show:

Lesion severity
Bifurcation anatomy
Flow characteristics

2. Initial Predilatation

Both LAD and LCX underwent:

2.0 mm balloon predilatation
Followed by 2.5 mm non-compliant balloon

Purpose:

Prepare lesion
Improve vessel compliance
Facilitate OCT imaging

LAD/LCX Predilatation with 2mm Balloon

LAD/LCX Predilatation with 2.5mm NC Balloon

Balloon predilatation sequence in LAD and LCX.

3. OCT Imaging – Pre-Stenting Assessment

OCT runs were performed in both LAD and LCX.

Findings likely included:

Plaque burden
Vessel diameter
Bifurcation angle
Calcification assessment

This guided the decision toward a 2-stent strategy.

OCT imaging run demonstrating plaque morphology and vessel sizing.

4. Cutting Balloon Strategy

Plaque modification is crucial in complex bifurcation lesions.

LAD:

3.0 mm Cutting Balloon dilatation

LCX:

Cutting Balloon dilatation

Post-cutting balloon OCT imaging was performed to confirm adequate lesion preparation.

Why cutting balloon?

Creates controlled micro-incisions
Reduces elastic recoil
Improves stent expansion

LAD 3/10mm Cutting Balloon dilatation

LCX – Cutting Balloon dilatation

Post Cutting Balloon OCT LCX OCT imaging
Cutting balloon expansion and post-modification OCT confirmation.

5. Stent Deployment – 2-Stent Technique

Given bifurcation complexity, a planned 2-stent strategy was executed.

Steps:

LCX stent placement
LM to LAD stent deployment
Sequential inflation

Precision is essential to avoid:

Carina shift
Side branch compromise
Geographic miss

Lcx, LM to LAD stent Placement.

Post LCX Stent Inflation

LM > LAD Stent Inflation

LCX stent placement followed by LM-LAD stent deployment.

6. Proximal Optimization Technique (POT)

POT was performed using:

5 mm / 6 mm POT balloon

Purpose:

Optimize proximal Left Main stent expansion
Ensure proper apposition
Facilitate LCX rewiring

LCX was rewired post-POT.

Subsequent steps included:

LAD OCT imaging
LCX ostial dilatation with 1.5 mm and 2.0 mm balloons

POT Inflation with 5mm/6mm POT Balloon

POT & LCX rewiring Post POT

LAD OCT Imaging

LCX Ostial dilatation with 1.5mm & 2.0mm balloon.

7. Final Kissing Balloon Inflation

Final kissing balloon technique performed using:

3.5 mm balloon
3.0 mm balloon

Followed by:

Final POT
Final OCT imaging

This ensures:

Symmetrical expansion
Proper bifurcation geometry
Optimal long-term patency

Final Kissing Balloon Placement (3.5/3.0mm)

Kissing & Final POT

Final POT & Final OCT Imaging.

Final kissing balloon inflation and OCT confirmation.

8. Final Angiographic Results

Final angiography showed:

Excellent flow
No residual stenosis
Well-expanded stents
Optimal bifurcation architecture

Views included:

AP Caudal / LAO Caudal
RAO Caudal / LAO Cranial

Final Result- AP Caudal/LAO Caudal

Final Result – RAO Caud/LAO Cranial.

Final angiographic result – before vs after comparison.

Post-PCI Medical Management

Given Left Main disease, aggressive lipid lowering was initiated.

Antiplatelet Therapy

Ticagrelor
Aspirin

Lipid Management

High-dose statin
Nikoran

Advanced Lipid Therapy

PCSK9 inhibitor (Day 1)
Inclisiran injection at 2 weeks
Maintenance dose every 6 months

The goal was:

Achieve very low LDL levels
Prevent future events
Optimize long-term stent patency

Post-Procedure Recovery

What truly defines this case is recovery.

Hemodynamically stable
No complications
Early mobilization

And remarkably…

Back to his Operating Theatre on Day 3.

For a surgeon, this means:

Restored stamina
Confidence
Trust in modern cardiology

Why This Case Is Clinically Significant

Demonstrates feasibility of complex Left Main PCI
Highlights importance of OCT guidance
Shows value of plaque modification
Validates structured bifurcation strategy
Proves rapid recovery is achievable with precision

This is modern interventional cardiology at its best.

Clinical Pearls for Cardiologists

Do not ignore symptoms with normal ECG/Echo
OCT should be strongly considered in Left Main cases
POT is non-negotiable in LM stenting
Final OCT confirmation improves outcomes
Patient selection is critical

Lessons for Patients

Chest pain should never be ignored
Early diagnosis saves heart muscle
Surgery is not always the only solution
Advanced PCI can offer excellent outcomes
Lifestyle and lipid control remain essential

Active Surgeon with Left Main Bifurcation Disease Managed by OCT-Guided Double Stent Technique