65 years maleCRF, on dialysis regularlyAwaiting renal transplantTypical angina symptomsCTCA triple vessels disease with high calcium scoreCoronary angiogram with left main disease , both LAD and LCX severe diseases, RCA CTOHeart team approach and explained to patient the choice of bypass or PCI with LVAD like impella supportAdvised by renal physician that transfusion with bypass may affect the future transplant of kidneyTherefore, opt for PCI with impella support
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Renal function is not a problem because regular dialysisThe case was done on the day before dialysisLoaded with Clopidogrel

Right and left femoral approachImpella was implanted successfully, and running smoothly with good haemodynamic support7F  EBU guiding catheterWires both LAD and LCX coronariesPre-dilated the lesions with simple balloon ,cutting balloon, and lithotripsy the severe calcified lesions and then IVUS the lesionsStents to LAD and LCX  and left main successfullyResults confirmed by IVUS Impella removed after the OT and patient was fineAngina free after one yearNo new kidney available for transplant
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Right and left femoral approach after local anaesthsia.Impella insertion inserted from the left femoral artery according to the procedure, first with pig tail catjheter, then exchanged with stiff wire.Inerted the Impella into the Left ventricle with the distal part above the aortic valve.7F EBU guiding catheter to the left sideWires both LAD and LCXPredilated with balloonIVUS the lesionsPrepared the lesions with cutting balloon and shock wave balloonStents the lesion upto the left mainResult confirmed by IVUS
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This is an unusual case with the patient refused the CAVBG because worried about transfusion of other people's blood which may affect the renal transplantationThe use of Impella in this kind of complex case is worth while.Cutting balloon and Lithotripsy were used before implantation of stentsAll the new technology were used in this case in order to have a good result