• Milorad Tesic, Djordje Mladenovic, Vladan Vukcevic, Dario Jelic, and Dejan Milasinovic.
• Clinic for Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia.
• Medicina (Kaunas). 2024 Sep 24; 60 (10).

IntroductionExcessive stent strut protrusion in the distal left main (LM) from either the left anterior descending (LAD) or circumflex (Cx) artery following inadequate ostial stenting may complicate any later procedure involving the left coronary artery. In such case scenarios, intravascular ultrasound (IVUS) guidance provides accurate assessment of the ostial stent position and may facilitate subsequent management strategies and treatment.Case SummaryWe present a complex percutaneous coronary intervention (PCI) of LM bifurcation in a 49-year-old man following inadequate ostial Cx stenting that resulted in excessive stent protrusion in the distal LM segment, accompanied by a subsequent short 80-90% ostial LAD stenosis. Initially, IVUS was performed to confirm "floating struts" from a previous Cx ostial stenting and to ensure complete intraluminal placement of the wire within the stent leading to the Cx, precluding any side passage through the stent struts. Then, a second wire was inserted into the LAD through the most distal stent strut under live IVUS guidance. Further PCI was completed according to the principles of the double kissing mini-culotte technique. Final IVUS runs confirmed correct stent apposition and expansion in the LM, LAD and Cx segments.ConclusionsIn cases involving the treatment of "free-floating" struts in the distal LM artery, intravascular imaging is essential to ensure optimal PCI outcomes.

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