Troponin I elevated at 890 Total cholesterol 3.9 LDL 2.3 HDL 0.96 Triglycerides 1.42 Hbaic 5.9%Creatinine 118 eGFR 55ml/min/1.73m2Echocardiogram shows Ejection fraction 40-45% with regional wall motion abnormalities at basal and mid inferior lateral wall, basal septal, mid anterior and basal anterior wall. TAPSE 2.1cm Normal Left and right atrium.

Diagnostic coronary angiogram via right radial artery was performed with Terumo 6 Fr sheath and Opti-torque 5fr catheter. The findings revealed a normal Left Main Stem, severe proximal to mid calcified disease in the Left Anterior Descending artery, subtotal occlusion in the mid Left Circumflex Artery, and mild to moderate stenosis in the mid Right Coronary Artery, with moderate to severe disease in the Right Posterior Descending Artery.

Coronary angioplasty to the left system using an EBU 3.5/6Fr guiding catheter. Left circumflex artery stenosis was addressed using microcatheter Asahi Corsair135cm and Fielder XT wire then after exchanged to Run-through floppy. Intravascular Ultrasound (IVUS) was done.The lesion was pre dilated with Artimes SC2.0 x 15mm 12atm and Wedge NC 3.0 x 15mm 20atm. A drug-coated balloon, Agent Monorail 3.0 x 30mm deployed to the distal portion of the left circumflex artery for 60 seconds. A Drug Eluting Stent was deployed in the proximal to mid segment of the left circumflex artery, utilizing Cre8 3.0 x 26mm. The final step involved post-dilation using Apollo NC 3.5 x 12mm 12atm, ensuring optimal outcomes in the revascularization process.   Left anterior descending artery angioplasty where by (IVUS) was conducted prior to intervention, revealing a proximal reference of 4.5mm, a distal reference of4.0mm, and the tightest mid-area Minimum Lumen Area (MLA) at 2.75mm with 270 degree calcifications measuring 3.5mm. The lesion was predilated using Apollo NC3.5 x 12mm, followed by Intravascular Lithotripsy (IVL) delivery with a 3.5mm device. Post-IVUS was performed to assess the results. Subsequently, additional pre-dilation with Apollo NC 4.0 x 12mm preceded the deployment of a Synergy Megatron stent measuring 4.0 x 32mm. Post-dilated using Apollo NC balloonsat4.0 x 8mm and 4.5 x 8mm. A final IVUS evaluation confirmed well-apposed stent positioning with no stent edge dissection. TIMI III flow.

The case involved the successful application of Intravascular Lithotripsy (IVL) in treating calcified lesions during coronary angioplasty. Intravascular Lithotripsy (IVL) is crucial for treating calcified lesions in coronary angioplasty, where calcium deposits in the arteries pose challenges to effective intervention. Calcium in the arteries can lead to vessel narrowing, reducing compliance and complicating stent deployment. IVL is important in such cases as it utilizes sonic pressure waves to fracture and modify calcified plaques, allowing for improved vessel compliance and enhancing the success of angioplasty procedures.