Mr J H, 68 years old hypertensive diabetic patient presented with exertional chest pain with shortness of breath for one and half months. He has history of PCI two times before in LAD, LCX and RCA in 2011 and 2017. Hia chest pain was not relived by taking antianginal medications. then we decided to do a coronary angiogram.

we did some laboratory investigations of our patients. HIS ECG showed, anterior ischemia. Echocardiography showed,no regional wall motion abnormality with preserved LV systolic function.

CAG showed TVD with calcified lesion in proximal LAD and significant ISR in distal segment. Proximal LCX has patent stent, minor lesion in distal part. RCA had significant ISR in proximal part and tight lesion in distal part. we decided to do IVUS and according to finding of IVUS we did PCI to RCA first , a DES was deployed in distal RCA and DEB in proximal ISR. We choose IVL to modify calcium in proximal LAD and a DES was deployed. DEB was use in LAD-ISR. IVUS was done to optimize the result.

we decided to PCI to RCA first. we did IVUS before  intervention. We prepare the lesion by inflate a NC balloon in distal tight lesion and proximal ISR. A DES was deployed in distal RCA after adequate predilatation. a DEB was done in proximal ISR. Post procedure IVUS was done. we staged the procedure, next day we did PCI to LAD. According to IVUS report we choose IVL as a calcium modification device and inflate it at 4 ATM pressure. Total 40 pulse generation were applied to achieve maximum grenadoblastic effect. IVUS was done after IVL to ensure calcium crack. Then a DES was deployed in proximal calcified lesion after adequate predilatation, post dilatation was done sequentially. A DEB was done in distal LAD-ISR. After the procedure we did a IVUS run. More than 90% MLA was achieved after the procedure with excellent stent expansion. Final angiogram showed a good distal flow in both the right and left coronary arteries.

Proper planning and suitable hardware are crucial for optimal procedural result. Image guided PCI provide excellent periprocedural comfort and post procedural outcome. Appropriate selection of calcium modification device plays a vital role when necessary. Newer technologies are evolving for the betterment of our patient ,we should welcome them and take their advantages to the fullest.