Mr NR

85 year old male known hypertensive, type II diabetes mellitus and known Triple vessel coronary artery disease with calcified left main disease. He was admitted with non ST elevation myocardial infarction. He had previously refused CABG following an angiogram for stable angina 2 years prior. A repeat angiogram was performed which revealed complex calcified coronary artery disease with SYNTAX score of 29. Physical examination was unremarkable and he was hemodynamically stable

His serum creatinine was 0.8mg/dl and troponin was significantly elevated. Electrocardiogram showed Right bundle branch block with ST depressions in I, aVL, V2-V4. Echo showed regional wall abnormality in Left circumflex territory and ejection fraction was 45%.

Coronary angiogram revealed severely Calcified coronaries. Left main was short and calcified. Left circumflex showed tandem lesions with 80% severity which were calcified and tortuous. Left anterior descending artery was calcified with a 80% ostial lesion and 90% mid lesion. Right coronary artery was calcified, with a distal intermediate lesion.

After a discussion in the heart team meet it was decided for a staged PCI approach, to intervene on Left circumflex artery first with intravascular lithotripsy for plaque modification and staged Procedure to left anterior descending artery later. In view of significant calcified, tortuous and aneurysmal segments it was decided to use intravascular lithotripsy instead of mechanical atherectomy. Left circumflex and LAD lesions were wired with 2 workhorse wires. We could track 1.25 and 1.5mm balloons with the help of guide extension catheter but were unable to dilate the lesion resulting in balloon ruptures. 2mm balloon could not be tracked even with the help of buddy wire and guide extension catheter. In view of multiple balloons rupturing and balloons not tracking an option of abandoning the procedure was considered. Then as a last option a 0.85mm NANO ballon was used which is a ultra-pressure non-compliant CTO balloon to dilate the lesion successfully without rupturing. Then we used a 1.5, 2.0, 2.5 semi compliant balloons sequentially to dilate the lesion. Then a 2.5 x 12mm IVL balloon was inflated to 6 atm and 80 pulses were delivered for plaque modification. After IVL, we checked lesion preparation by ensuring optimal expansion of 3mm balloon at low pressures to avoid stent regret. A 2.75 x 38 and 3 x 16mm overlapping stents were deployed successfully in LCX. Good expansion was seen on IVUS run with distal TIMI III flow

Heart team approach is necessary in complex cases. Preprocedural planning is crucial for a successful procedure. Intravascular lithotripsy is useful in situations were mechanical atherectomy is not possible. A 0.85mm ultra high pressure non compliant Balloon is a good addition incases of undilatable lesions or calcium spicule