TA

73 years old lady with history of Atrial Fibrillation, Chronic Kidney Disease Stage, Hypertension, Diabetes Mellitus, HFrEF ~38%, history of pangastritis, presented with chest pain for 2 weeks. She was previously ADL independent. 
Clinically, shewas alert, mildly tachypneic with warm peripheries. BP - 156/80 mm HgHR - 76 bpm, regularSpo2 : 97% on NP3LLungs : clearCVS : DRNMmild pedal edema

2DTransthoracic Echocardiography : LVEF 38%, septal and anterior wallhypokinesia, IVSD 1cm, no LV clot, Grade 2 diastolic dysfunction,TAPSE 17cm, mild mitral regurgitation, no pericardial effusion
CXRcardiomegaly,no pleural effusion
ECG: atrial fibrillation , rate controlled 
BloodInvestigations :Hb 12.7g/dl, WCC : 12.8 x 10⁹ /L , Platelet : 177 x 10⁹/ LUrea 9.5 mmol/l , K+ 4.6 mmol/l, creatinine150 umol/l ( eFGR  30 )ALT  :14 U/L , Troponin 475 pg/ml, NTproBNP : 75
Diagnosis :NSTEMI

Coronary Angiogram done via right radialapproach , 6F sheath, 5F Optitorque catheter usedFINDINGS :Left main :normalLAD : severeproximal to mid segment disease , heavily calcified , severe diagonal diseaseLCX :moderate disease at mid LCXRCA : severeproximal RCA disease, heavily calcified
Patientdeclined CABG. In view of NSTEMI and persistent chest pain in ward, offeredhigh risk PCI to LAD with atherectomy and staged PCI to RCA later. Patient and family agreed.

PCI to LM / LAD / Diagonal withAtherectomy RFA,7F sheath,EBU 3.07F guide enganged LM.SION Blue wired into LAD.IVUS pre PCI,showed tight ostial LAD upto mid LAD with heavy calcium and concentric calcium ring at proximal LAD.Decided forRotablation with Rotapro.Rotawire floppy drive advanced into LAD withmicrocatheter. Rotablation done at ostioproximal LAD at 180k rpm with5 consecutive runs.Exhanged with SION Blue.Runthrough Floppy wired into Diagonal.Predilated LAD with NC 2.0x15mm,NC 2.5x15mm,NC3.0x15mm sequentially.However,still noted lesion not well prepared,NC balloon not fully expanded.Decided to use Intravascular Lithotripsy (IVL) balloon.IL shockwave balloon 3.0x12mm used with 8 cycles of 10 pulses performed at nominalpressure.Noted balloon expansion better.Stented prox LADwith DES 2.5x32mm at nominal. However, stent still not well expanded at calcified segment.Postdilated prox LAD stent with NC 3.0x15mm at 12-22ATM.RTF in Diagonal rewired into LCX. Stented ostial LM/LAD with DES 3.5x24mm.Postdilated with NC 3.5x12mm at 14-20ATM.POT LMwith NC 4.0x6mm at 18ATM. IVUS showed well opposed LM and proximal LAD stent.Proximal LAD stent incalcified segment showed better expansion.Rewired LCX into distal struts.Kissingballoon inflationdone wit NC 3.5x15mm and NC 3.0x15mm at nominal.FinalPOTdone in LM with NC 4.0x6m at 16 to 20 ATM.FinalIVUS showed well opposed stent, no stent edge dissection and good MSA achieved ( Ostial LAD MSA 9.92mm2 , prox LAD MSA 6.02mm2 )

Learning points 1.      1. Pre-procedural planning and safety measures will minimize possible complications and gives safe and better outcome2.     2. We aim to highlight the use of hybrid approach ;  2 different modality of atherectomy devices ( Rotablatian & Intravascular Lithotripsy ) which greatly           assisted good lesion preparation, plaque modification and calcium debulking in this case3.     3. Stent under-expansion leads to worse MACE in long term4.    4. DES with short DAPT strategy used in this particular patient who we deemed as high bleeding profile.