From aVR Elevation to Recovery: Emergency LM–LAD Stenting and TAP to LCX in Acute Left Main Occlusion

Abstract

Background: Acute left main (LM) coronary artery occlusion is a rare but catastrophic cause of ST-segment elevation myocardial infarction (STEMI), frequently associated with cardiogenic shock and high mortality. Prompt diagnosis and rapid revascularization are critical.

Case Presentation: A 58-year-old diabetic and hypertensive male presented with severe chest pain for 8 hours. ECG revealed significant ST-segment deviations with ST elevation in aVR, suggestive of LM or proximal multivessel ischemia. Primary PCI strategy was undertaken. Coronary angiography demonstrated a normal RCA but complete occlusion of the left coronary system immediately distal to the LM bifurcation. The patient became acutely hemodynamically unstable following contrast injection.

Intervention: Emergency PCI was performed with IVUS guidance. The LAD and LCX were successfully wired. LM-to-LAD stenting was performed as the main strategy, followed by TAP (T and Protrusion) technique for LCX access. Kissing balloon inflation (KBI) and a final proximal optimization technique (POT) were executed, achieving optimal stent expansion and bifurcation geometry. TIMI 3 flow was restored in both LAD and LCX.

Outcome: The patient stabilized hemodynamically with excellent angiographic results and no immediate complications.

Conclusion: This case highlights the importance of recognizing ST elevation in aVR as an indicator of potential LM occlusion and demonstrates that IVUS-guided LM bifurcation PCI using a TAP strategy with KBI and POT can achieve rapid and effective revascularization in critically unstable patients. Urgent mechanical revascularization remains essential in the management of acute LM STEMI.