A 76 year-old-man presented with typical chest pain while on hemodialysis for 1 week. His underlying diseases were ESRD s/p HD, HT, DLP, paroxysmal AF and IHD s/p multiple episodes of PCI with DES at LM-proximal LAD, mid LAD and mid RCA then develop severe ISR so patient underwent  CABG x 2 times in 2021 and redo in 2022 due to graft failure.At ER he had no chest discomfort and no orthopnea or PND.Physical examination BP 160/90 mmHg HR 80/min no crepitation regular rhythm normal s1s2 no murmur.

CXR showed cardiomegaly without cephalization or pulmonary congestionEKG showed sinus tachycardia rate 70/min LAD LVH with horizontal st depression in V5-V6LAB hsTnI = 20.3 ng/L NT-pro BNP > 35,000 pg/ml Hct 32.4 Bun 66 Cr 12.6Echo dilated LV size with severely impaired LV systolic function LVEF = 26% by Biplane with RWMAs hypokinesia in anterior, septal and inferior wall from bas to apex, no evidence of LV thrombus, no pericardial effusion

There was 80% mid to distal LM bifurcation (ISR at LM-LAD stent: Onyx 3.0x15 mm) Medina 1-1-1. 95% stenosis at proximal LAD, 100% stenosis at mid LAD, 80% calcified stenosis at proximal Lcx 100% stenosis at mid RCA (ISR at Cypher stent unknown size).There was 80% stenosis at mid SVG to PDA. Patent SVG to LAD and SVG to OM.

Culprit lesion was LM to proximal Lcx.A 7 Fr XB 3.5 guiding was engaged into LCA via right femoral artery.A Sion blue ES wire with 130cm fine cross microcatheter could advance into distal Lcx then wire was exchanged to RotaExtrasupport wire.Rotablator was done at Lm-proximal Lcx with Burr 1.75 at 190,000 rpm x 7 runs but could not pass lesion. Step down to 1.5 burr was done at 170,000 rpm x 3 runs and could pass lesion. step up burr to 1.75 at 170,000 rpm x 1 run for further debulking.A sion blue ES was wired to distal Lcx, A Fielder FC was wire to distal LADPre-dilated at proximal Lcx with NC balloon 3.5x15 mm at 20 atmResolute Onyx 4.0x22 mm was deployed at LM-proximal Lcx at 14 ATMFielder FC was retracted into guiding and rewire to mid LADstrut opening was done at LM-LAD with SC balloon 1.5x15 mm at 14 ATMPOBA was done at proximal LAD with NC balloon 3.0x15 mm at 20 ATM follow by DCB 3.0x20 mm at 10 ATMPost-dilated at LM-LCx was done with NC balloon 4.0x15 mm at 18 ATM.Final angiogram showed well expanded stent at LM-LCX with good coronary blood flow to both LAD and Lcx without evidence of complicationsWe also performed PCI to SVG to PDA using JR4 guiding and FilterWireEZ and direct stent with Resolute Onyx 5.0x30 mm at 16 ATM for complete revascularization in this patient.

In this case we demonstrate that PCI in patient post CABG patient by correcting both native vessel and graft could be performed safely when surgical risk for redo CABG was high. Rotablator though previous stent may be difficult and required higher rotaspeed than usual. If rotaburr could not passed lesion step down of burr size was another option to pass lesion and then step back to previous burr size for adequate lesion preparation before pre-dilatation and stenting.