The 69-year-old male businessman with pasthistory of type 2 diabetes mellitus, chronic kidney disease stage 3, CAD-TVD statuspost CABG in 2013/05. He suffered from intermittent chest pain for one day andwas diagnosed of acute coronary syndrome with cardiogenic shock in 2023/05. After balloon angioplasty at middle rightcoronary artery at the referring hospital, the patient gotstabilized. He was referred to our hospital for complete percutaneouscoronary intervention.

EKG revealed normal sinus rhythm with V5-6 ST segment depression. Chest x-ray showed bilateral lung increased infiltration. Lab data revealed elevated creatinine level to 1.46mg/dl. 

           The right coronary artery has severe atherosclerosischanges and thick rotating calcification all the way from ostium to the RCA-PL, 90% stenosis with TIMI II flow down to RCA-PL. 90% ostial stenosisfollowed by diffuse 70% stenosis in the whole left main coronary artery. There arediffuse atherosclerosis changes with heavy eccentric and rotatingcalcification, 60-80% stenosis on LAD. LCX also surrounded by diffuse atherosclerosischanges, heavy calcification and 95% stenosis at ostium.

          Due to complex anatomies in left coronaryartery and diffuse lesions in the right coronary artery which are notmanageable in this stage, Impella (Abiomed, U.S.) was needed for hemodynamic support. A14Fr sheath could not be advanced through the heavily calcified common iliacartery (CIA). To avoid damage of Impella, CIA was treated with intravascular lithotripsy(Shockwave Medical, U.S.). Impella was advanced without any difficulty.          Intervention for LAD was approached via femoral access. We treated LCXwith 1.25mm Rota burr (Boston Scientific, U.S.) for bias cutting with anextra-support rota wire (figure A). Then, we advanced a wire accompanied withmicrocatheter down to distal LAD. Since the blood flow of LCX was TIMI 3, theextra-support rota wire was switched to LAD, followed by debulking theLAD-os-P-M (just short of the LAD-M-D-D2 bifurcation to avoid vesselperforation) with a 1.25mm burr (figure B). The wire was switched back to aworkhorse wire and we also rewired into LCX. All the lesions could be fullyexpanded with the semi-compliance balloon. Due to severe dissections in LCX,the distal LM to LCX-P was scaffolded with a drug eluting stent (DES) to securethis vessel firstly (figure C). Then, we did Culotte technique at left mainbifurcation lesion. The LAD-M-D and LM/LAD-os-P-M were respectively scaffoldedwith DES. Kissing balloon technique and proximal optimization technique weredone at LM. Due to hemodynamically stable, Impella was removed.

        The Impella provided adequate hemodynamic support during high-risk PCI. We should avoid bailout use mechanical support. On the other hand, if we rotablate exactly where needed, we can avoid troubles.