Title : Triple triumph: Complex multivessel PCI with rotational atherectomy and intravascular lithotripsy for left main, ramus, and LCx CTO in a severely calcified post-CABG patient
Abstract:
Chronic Total Occlusions (CTO) and severe coronary calcification present significant challenges in Percutaneous Coronary Intervention (PCI), especially in patients with prior Coronary Artery Bypass Grafting (CABG). This case highlights a single-session PCI addressing Left Main (LM), Intermediate Ramus (IR), and Left Circumflex (LCx) CTO using advanced calcium modification and imaging strategies.
A 73-year-old male with diabetes, hypertension, hyperlipidemia, and prior CABG presented with exertional dyspnea and a reversible inferolateral perfusion defect. Angiography revealed patent LIMA-LAD, occluded saphenous vein grafts (SVGs) to IR and RPDA, and severe, heavily calcified native multivessel disease: 75% distal LM, 90% proximal IR, and 100% proximal LCx CTO. The patient previously underwent successful rotational atherectomy and stenting of a functional RCA CTO.
For the current procedure,7F right femoral access was obtained. Rotational atherectomy (1.5 mm burr) was performed in the LM and IR, followed by Intravascular Ultrasound (IVUS) confirming extensive 360° calcification. Intravascular Lithotripsy (IVL) was applied with 3.0 mm and 4.0 mm shockwave balloons in the IR and LM, respectively. The LCx CTO was crossed using a microcatheter and specialized wires, then predilated and stented (Orsiro 2.5 x 30 mm). The LM was stented into the IR (Synergy XD 3.5 x 38 mm), with post-dilation and kissing balloon inflation at the LM-IR/LCx bifurcation. IVUS confirmed optimal stent expansion. Post-procedure TIMI III flow was achieved in all vessels with no complications. The patient was discharged the next day on dual antiplatelet therapy with preserved ventricular function.
This case demonstrates the feasibility and safety of combined rotational atherectomy and IVL for severe coronary calcification, enabling successful multivessel PCI-including LM, ramus, and CTO recanalization-in a single session. Rotational atherectomy and IVL were critical in modifying severe calcification, while IVUS provided precise vessel sizing and stent optimization. The successful trifecta of interventions in a single setting is rare and highlights the potential for comprehensive revascularization in complex CAD, potentially reducing procedural risks and recovery time.
