"Less Metal" in a Complex Left Main Trifurcation Lesion

Management of complex left main (LM) coronary artery trifurcation lesions remains a significant challenge. Herein, we report a case where a provisional stenting strategy was employed in a patient with distal LM trifurcation lesion involving left anterior descending artery (LAD), left circumflex artery (LCx) and ramus intermedius (RI). A single drug-eluting stent (DES) was deployed from the LM into the LAD, while the LCx managed with a drug-coated balloon (DCB) and RI conservatively as already had a previous ostial stent. Intravascular ultrasound (IVUS) was utilized throughout the procedure to assess coronary anatomy, lesion morphology and guiding stent sizing and placement. Post-procedural IVUS imaging demonstrated good stent deployment without malapposition, edge dissection, or residual disease. This case underscores the feasibility and safety of a hybrid approach incorporating provisional stenting and DCB therapy in selected LM trifurcation lesions, with IVUS guidance playing a critical role in procedural success.