A 71 years female with underlying diabetes, hypertension hyperlipidemia, Presented with STE inferior MI, referred to our center for PPCI. Echo: EF 55% inferior wall hypokinesia. Angiogram: Tight distal LMS stenosis, calcified diffuse LAD disease, calcified with tight lesion proximal and dLAD. Planed for immediate IABP insertion and urgent as in-patient CABG. Before IABP insertion, aortogram showed calcified and bilateral severe aorto-iliac stenosis. 

Surgical team advised to  fix her PVD. PTA aortoiliac done prior to CABGstented Aorta & both Iliac arteries

 , but 2 days later developed UTI, surgery was postponed waiting infection to clear. while waiting for CABG,, she developed STE posterior-inferior MI with pulmonary edema and pneumonia (HAP). Urgent CABG was postponed waiting chest infection to clear. She continued to have chest pain, BP dropped & required Inotrope support, trop T went up 5000 Patient she was counselled for high risk PCI vs waiting CABG 

patient was brought for urgent high risk angioplasty  via LFA for IABP insertion & RFA for PCI using EBU 3.0/7F. decided for upfront Rotablator because IVUS cath couldn't pass across the pLAD lesion. Rotapro 1.5 Burr at 80000rpm/ 5runs from LMS to mLAD. Then predilated with  Predilated with  scorflex 2.5/15 & 3.0/ 15.Stented mLAD to pLAD, DES 2.5/28, Up sized with NC 3.0/15, Stented pLAD to ostial LMS ,DES 3.5/28,Upzised at LAD with NC 3.5/12, And POT LMS NC 4.0/8. PCI to RCAJR catheter 6F , upfront Rota burr 1.5 @180rpm/4 runs to proximal to mid RCA. Then  predilated with scoreflex 2.5/15. Stented pRCA up to ostium with DES 3.0/28, Upsized with 3.5/15.DCB mRCA with 3.0/30.

Post procedure was pain free, discharged home well after 2 days.
take home massage