NBO

Mr. NBO is a 61-year-old gentleman with underlying hypertension, history of ICB in year 2006, ESRF with tertiary hyperparathyroidism on regular hemodialysis, paroxysmal AF on Watchman device, as well as a known case of stable IHD with moderate LAD disease and CTO OM, presented with intradialytic chest pain and shortness of breath. He was diagnosed as having non-ST elevation Myocardial Infarction.
His vitals was stable with BP 110/73mmHg, HR 70bpm. Cardiovascular examination was unremarkable.

ECG showed atrial fibrillation.
Blood investigations showed hemoglobin 13g/L, Troponin T 713pg/ml, Urea 13.8mmol/l and Creatinine 800umol/l.
Echocardiogram showed good EF with no regional hypokinesia.

Coronary angiogram showed distal calcified moderate LMS disease. For LAD, it was a diffusely calcified vessel with moderate disease from Ostia to proximal region with severe subtotal occlusion mid LAD, distal region was also calcified and diseased. Diagonal branch was severely calcified. LCX showed severe calcified ostial disease with CTO OM similar to previous angiogram in 2016. Only mild disease of RCA.
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The subtotal LAD occlusion was crossed with guiding catether EBU 3.5and RUNTHROUGH FLOPPY wire with RYUREI 1.5 x 15mmballoon support. Predilatationwith 1.5 x 15mm balloon was performed. We planned to perform IVUS to assess the vessel anatomy however IVUSfailed to pass through the narrow tract. We then proceeded to performRotablation with ROTABLATOR 1.25 burr at 160,000 rpm for 4runs to the proximal and mid LAD, followed by successful IVUS to LAD. IVUS showed severe, circumferential calcified stenosis in the mid LAD with tightest MLA 1.75 mm2. Entire length of proximal to mid- distal LADwas heavily calcified with different degree of stenosis. We then further prepared the mid LAD with SCOREFLEX NC 2.5 x 15mmand 3.0 x 15 mm scoring balloon. We decided for a non-stent strategy due to diffuse heavily calcified disease in the LAD without a ‘normal’ landing zone for proper stent sizing and placement. Drug coated balloon with SEQUENT PLEASENEO 2.75mm x 30 at distal lesion followed by 3.0 x 30mm at proximal lesion was performed. POST DCB IVUS showed improvement of mid LAD MLA to 4.22 mm2. A small non-flow limiting type A dissection was noted with TIMI III flow and results were accepted. Patient achieved good recovery with no further intradialytic angina and was discharged well.
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A non-stent strategy was chosen in this case in view of several reasons.1. The diseased vessel is heavily calcified without a ‘normal’ landing zone for proper stent sizing and placement2. Patient has high bleeding risk with history of ICB, regular hemodialysis and atrial fibrillation. Drug Coated Balloon approach allows shorter dual antiplatelet therapy duration which reduces bleeding risk, as well as avoiding risk of in-stent restenosis while achieving good revascularization and symptom relief in this patient group.