Background: Current guidelines state that it is reasonable to consider unprotected left main PCI in patients with low to intermediate anatomic complexity who are at increased surgical risk. (1) Coronary bifurcation lesions are considered technically challenging and associated with worse clinical outcomes. (2) We present a complex left main bifurcation lesion treated with a dedicated sirolimus eluting bifurcation stent, BiOSS Lim in combination with plain balloon angioplasty (POBA) of circumflex artery. The dedicated stent protects the carina from being damaged, the large cell at the middle zone gives possibility to enter easily into the side branch with any standard size conventional device. (3)

Case report: 90-year-old man with a history of hypertension and non ST-segment elevation myocardial infarction (NSTEMI) which he had suffered five months earlier presented with an unstable angina. During hospitalization unstable angina has evolved to NSTEMI leading to acute pulmonary edema. Diagnostic coronary angiography revealed a 90% stenosis in distal left main coronary artery (LM), 80% stenosis in proximal segment of circumflex coronary artery (Cx) and 90% stenosis in mid and distal segment of right coronary artery (RCA). SYNTAX score was 22. For PCI SYNTAX Score II was 41.5 with predicted 4 year mortality of 16.9% and for CABG it was 52.9 with 4 year mortality of 38.3%. EuroSCORE was 29.16% and EuroSCORE II was 9.58%. Considering calculated scores and patient’s wish to be treated by less aggressive medical procedure, PCI was performed. PCI was performed using a right radial artery approach. With 6F JL 4 catheter the left main coronary artery was engaged. A Runthrough Floppy str/180-cm was placed in distal segment of Cx and another wire, Whisper MS str/190 cm was placed in distal segment of LAD. Predilatation in distal LM was done with balloon PTCA catheter Mini Trek 1.20x15 mm and afterwards with balloon Mini Trek 2.5x15 mm. Then a bifurcation drug eluting stent (DES) BiOSS Lim 3.0 distal – 3.75 prox. was implanted, with the larger diameter in distal segment of LM and with smaller diameter in proximal segment of LAD. After BiOSS Lim stent implantation, POBA was performed in mid segment of Cx without predilatation to dilate the stent struts. Final angiography showed adequate flow. This is the first use of BiOSS Lim stent in University Hospital Centre Split.