Mastering the Challenge: Complex Left Main (LM) Disease, Anterior Wall Myocardial Infarction (AWMI), and the Jailed Semi-Inflated Balloon Technique (JSBT)

Abstract

Background: Coronary bifurcation lesions account for up to 20% of coronary lesions, with side branch (SB) compromise being a significant concern when stenting. Provisional bifurcation stenting is the preferred strategy, and the JSBT offers a novel approach to preserve the SB during stenting by temporarily ‘jailing’ a semi-inflated balloon in the SB, reducing risk of occlusion. We present a case of AWMI with complex LM disease treated with primary percutaneous coronary intervention (PPCI) using JSBT. Case: A 35-year-old male smoker, known for coronary artery disease, had a coronary angiogram 2 days back showing LM and 3-vessel disease. Coronary artery by-pass grafting was advised, but he left against medical advice. He presented with chest pain, and an electrocardiogram (ECG) confirmed AWMI. Dual antiplatelet therapy and heparin were initiated, and he was transferred to the catheterization lab. Angiography showed Distal LM 80%, Proximal LAD 99%, proximal Ramus 70%, proximal Left circumflex 90%. Right coronary artery was non-obstructive. PPCI of the LM-LAD and Ramus was performed via JSBT. A 3.5x38 mm drug-eluting stent was deployed in the LAD, and a 2.0x15 mm semi-compliant balloon was placed in Ramus. After stent deployment, post-dilation and proximal optimization (POT) with a non-compliant balloon were performed. after Post-dilation Ramus flow was compromised, and kissing balloon inflations restored TIMI-III flow in both LAD and Ramus with Type-B dissection in Ramus. The patient was monitored in the CCU on tirofiban and dual antiplatelet therapy, then discharged in stable condition. At one year, he remains asymptomatic and compliant with treatment. Conclusion: This case highlights the effectiveness of JSBT for stenting in complex, high-risk coronary artery disease cases with excellent procedural outcomes.