T-Stenting Technique for Iatrogenic Left Main–LCX Dissection: A Case Report

Abstract

Iatrogenic left main (LM) dissection is a rare but life-threatening complication of PCI that can result in abrupt occlusion of both LAD and LCX, especially when the LCX is dominant, leading to hemodynamic collapse and conduction disturbances such as complete heart block (CHB). We present the case of a 58-year-old male with evolving anterior wall MI who developed LM–LCX dissection during PCI, causing TIMI 0 flow in both LAD and a dominant LCX. Because the LAD supplied the largest myocardial territory, LM–LAD stenting was performed first to restore perfusion to the majority of myocardium, followed by bailout T-and-Protrusion (TAP) stenting of the dominant LCX with final kissing balloon inflation (FKBI) and proximal optimization technique (POT), achieving TIMI 3 flow in both branches. The patient recovered fully and was discharged on guideline-directed therapy. T-stenting was one of the earliest bifurcation techniques, and its refinement, TAP, allows optimal side branch ostial coverage with minimal metal overlap (7). Contemporary studies confirm that TAP, when performed with second-generation DES, FKBI, and POT, offers excellent outcomes comparable to more complex techniques such as DK-crush. This case highlights TAP as a rapid, effective, and lifesaving bailout strategy in LM bifurcation PCI, particularly when both branches are occluded but priority must be given to revascularizing the main branch supplying the largest myocardium.