SSH

Mr SSH is an 80-year-old ex-smoker with underlying hypertension,an overactive bladder, and a family history of ischemic heart disease,presented with CCS II exertional angina for months. Physical examination wasunremarkable, with a well-controlled blood pressure of 128/70 mmHg and a heartrate of 70 beats per minute. 

The electrocardiogram showed no sign of ischemia. The echocardiogramwas normal, with a left ventricular ejection fraction of 58% with no regionalwall motion abnormality. His LDL was 102 mg/dl, eGFR 60 ml/min, and HbA1c of5.7. 
He underwent Coronary Computed Tomography Angiography (CCTA),which showed a calcium score of 545 with a high possibility of severe stenosisof the proximal left anterior descending artery (LAD) and modera

CAG showed distal left main (LM) 50% stenosis, severecalcification of LAD, 75% stenosis of pLAD, 50% stenosis of mLAD,ostial LCx 90% stenosis and mild disease of PDA.LAD FFR was 0.74 with 0.23 step up over thepLAD. 
This is a true bifurcation, Medina 1,1,1 lesion with LM involvement. Syntax I score - 30, Syntax II score of PCI vs CABG was 35.9 vs 42.9; with a 4-year mortality of 10.9% vs 18.8%. 

The case started with 8Fr RFA approach, LCA engaged with GOODMANROADMASTER 8Fr, CLS 40 SH. LAD wired with SION BLUE wire and IVUS with TERUMO ALTAVIEW.IVUS showed circumferential napkin ring calcium over pLAD to mLAD, dLM calcificationwith moderate plaque burden; ostial LCx showed heavy plaque burden. Calcium debulking performed with BOSTON ROTAPRO 2.25mm burr fromdLM to mLAD for 4 rounds at 220000rpm. Subsequent IVUS showed good debulkingwith reverberation sign and calcium ring fracture. As IVUS of ostial LCx showedsuitable anatomy for DCA and to simplify the bifurcation treatment strategy, wedecided to perform DCA to ostial LCx. LCx wired with SION BLUE, then exchangedto NIPRO ABYSS DCA 3M wire. After confirming the area of interest with IVUS,DCA performed with NIPRO ATHEROCUT L Size, 6mm for 11 rounds, up to 3atm. PostDCA, IVUS and CAG showed good acute luminal gain from 2.23 mm² to 10.42mm².
Ostial LCx further prepared with GOODMAN NSE ADVANCE 3.5mm x13mm scoring balloon at 16atm. Distal LM to pLCx treated with SEQUENT PLEASENEO 3.5mm x 15mm DCB at 8atm for 60s.  tomLAD prepared with TERUMO RYUREI 3.0mm x 15mm SC balloon followed by NSEADVANCE 3.5mm x 13mm balloon. Then, ostial LAD to mLAD stented with RESOLUTEONYX 3.5mm x 34mm DES under IVUS guidance. Final CAG and IVUS showed good stentapposition and expansion, MLA of 16.81 mm² for LM, 10.50 mm² forLCx and 8.9 mm² for pLAD with no stent edge dissection. Totalprocedure time: 135 minutes; contrast 100ml.

The use of intravascular imaging allows the PCI operator to properlyunderstand the plaque distribution and vessel anatomy, thus, enabling us tochoose the correct debulking tools in a complex calcified bifurcation PCI. Wedemonstrated that the supposedly 2-stent bifurcation PCI can be turned into ahybrid DES-DCB PCI with good angiography and intravascular outcome with the combination use of Rotablation, DCA, and scoring balloon.