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A 62-year-old lady with recent stroke and severe LV impairment was referred for an angiogram. Angiogram showed severe calcified stenosis of LMS and all 3 vessels. She was turned down for surgery. PCI to the RCA was done uneventfully (image) and she was brought back for PCI to LMS/LAD/LCx a week later. In view of the severe calcification, we planned to use Intravascular Lithotripsy +/- Rotablation to aid the PCI with OCT imaging guidance.

ECG: Sinus rhythm, T inverted lateral leads, left ventricular hypertrophyLab: Hb 116 g/L, BNP 2542 pg/ml, Troponin I 0.32 ng/mLEcho: Dilated LV size. Global LV hypokinesia. Normal RV function. TAPSE 1.9 cm. Poor LV systolic function. LVEF 31%. Severe LV diastolic dysfunction. Mild mitral regurgitation. Trivial aortic regurgitation. Trivial pulmonary regurgitation. Mild tricuspid regurgitation. PPG: 25 mmHg. Mild global pericardial effusion / over RA 1.0 cm. No vegetation, thrombus or PFO.

LM - Distal LM 50%LAD - Severe calcification, with diffuse ostial to mid LAD 60-70%LCx - Severe calcification with ostial LCx 70%, mid LCx 70%RCA - Proximal RCA 80%, mid RCA 70%

RAO CRA Angio.mp4
CAU Angio.mp4
RCA Angio.mp4

The PCIwas performed from the Right Radial Access using 6F ‘Slender’ glidesheath and a7F EBU 3.5 guiding catheter. OCT in the LAD showed 270 degrees calcificationnear the diagonal branch. LCx pre-dilated using a 2.0 x 15 mm ‘Sapphire’NC balloon. Unable to pass a 2.5 x 10 mm ‘Wolverine’ cutting balloon. A 2.5 mmIntravascular Lithotripsy passed but slipped repeatedly during inflation.Further pre-dilatation with a 2.5 x 15 mm ‘Sapphire’ NC balloon was done. The2.5 mm ‘Shockwave’ balloon was then used to treat the ostial LCx, expandedafter 50 pulses. The LCx pre-dilated further with a 2.5 x 10 mm cuttingballoon. The same “Shockwave” balloon placed in the LAD ostium backto the LMS and the remaining 30 pulses were delivered with good effect. The LADwas pre-dilated with a 2.5 mm NC balloon. A ‘Xience’ 2.75 x 12 mmDES deployed in LCx, post-dilated with a 3.0 mm NC balloon and crushed with a3.0 mm NC balloon in LM-LAD. Wire recrossed and kissing balloon inflation (KBI)performed. ‘Xience’ 2.25 x 23 mm and 3.0 x 33 mm DES deployed from mid LAD toostial LM, followed by POT with a 3.75 x 12 mm NC balloon in LMS. LAD stents post-dilatedwith a 3.0 mm NC balloon. LCx rewired and KBI was performed with a 2.75 mmballoon in LCx and a 3.0 mm NC balloon in LAD. There was an irregularappearance in LCx ostium. We were unable to pass the OCT catheter. A 3.0 mm NC balloonwas passed into the LCx and a final KBI was performed. Final result wassatisfactory.
CRA Angio.mp4
CAU Angio.mp4
OCT LAD.mp4
NC 20 LCx.mp4
NC 25 LCx.mp4
IVL 1 LCx.mp4
IVL 5 LCx.mp4
IVL 6 LAD.mp4
IVL 8 LAD.mp4
NC 25 mLAD.mp4
NC 25 LMLAD.mp4
Lesion prepared.mp4
Stent 275 LCx.mp4
NC 30 LCx.mp4
Post stent LCx post NC.mp4
LCx stent crushed.mp4
LCx Rewired.mp4
1st KBI.mp4
Stent 225 mLAD.mp4
Stent 30 LMLAD placed.mp4
POT 375 LM.mp4
2nd KBI.mp4
Post 2nd KBI.mp4
LCx NC 30.mp4
3rd KBI.mp4
Final Angio CRA.mp4
Final Angio CAU.mp4
LAO CAU Angio.mp4
Final Angio LAO CAU.mp4

In this patient with severe LV impairment and complex LMS bifurcation stenosis, IVL, along with cutting balloon, helped us to treat the heavy calcification effectively and complete a successful DK Crush bifurcation stenting.IVL in the LMS was well tolerated with no hemodynamic compromise during balloon inflations. It is important to observe sufficient intervals between inflations and monitor the pressure carefully.