HBH

Mr HBH is a 68 year old gentleman, active smoker of 35 pack years, with hypertension and dyslipidemia. He was referred from a district hospital due to admission in August 2020. He presented with typical chest pain and diaphoresis, then was treated for a NSTEMI. Physical examination was unremarkable.
20220726_131910.mp4
20220726_132034.mp4
20220726_132441.mp4

ECG done showed sinus rhythm with T wave in version over anteriorleads. Troponin I was 3.54. Echocardiography in October 2020, showed anejection fraction of 60%, no regional wall motion abnormalities with trivialaortic regurgitation. His renal function was normal with a creatinine of 80umol/L.
20220726_132727.mp4

20220726_133046.mp4

Coronary angiography done in May 2022 showed single vessel diseasewith a short LMS, calcified LAD with ostial LAD CTO and collaterals from RCA,LCx was smooth, RCA was dominant with mid segment RCA having 30 – 40% stenosis.He was subsequently planned for a stage PCI to CTO LAD in July 2022.  
20220726_133721.mp4
20220726_134055.mp4
20220726_134303.mp4

Bilateral puncture with 6Fr sheath for right radial access and 7Fr sheath for right femoral access. EBU 3.5 7FR engaged to left coronary circulation and JR 3.5 6Fr engagedto RCA.Fielder XT-A wire into Firecross microcatheter then wired todistal LAD, exchanged to Sion Blue wire.Predilated distal LAD with Ryurei 2.0 x 15 mm at 6 - 10 ATMDone 1st IVUS, showing multiple calcium nodules along LAD. Distal LADsize 2.5 mm with MLA 4.11 mm2. Mid LAD MLA 2.87 mm2, proximal LAD MLA 3.13 mm2with plaque burden 70 % and ostial LAD had 180 degree calcium, MLA 5.21 mm2.Done Rotablation to LAD with 1.75mm Rota burr for 5 cycles at 165000to 175000 RPM.Predilated LAD with Accuforce 3.0 x 15mm at 12 - 16 ATM.Stented mid LAD with DES Synergy 2.5 x 48mm at 11 - 16 ATM.Stented proximal LAD with DES Synergy 3.0 x 48mm at 11 - 14 ATM.Stented ostial LM - LAD with DES Synergy 3.5 x 38mm at 11 - 14 ATM.Postdilated mid LAD with NC Euphora 3.5 x 15mm at 16 - 24 ATM.Postdilated proximal LAD and done ostial LM flare with NC Emerge4.0 x 12mm at 10 - 20 ATM.
20220726_134516.mp4
20220726_134538.mp4

IVUS run post, no stent edge dissection, well opposed and well expanded. Distal LAD MLA 5.78 mm2, mid LAD MLA 8.10 mm2, proximal LAD MLA 12.96mm2. Stent covered till ostial LM and LM - LAD MLA was 12.28 mm2.Final cine showed TIMI 3 flow with good results, no dissection, no perforation seen.No significant ECG changes during procedure.No other immediate complications.Procedure was concluded and then patient was discharged well post procedure the following day.