PMC9808482_01
Multimodal images in Case 1 (A-C) Coronary angiography (CAG) showing multivessel disease (dotted lines). (D-F) Coronary computed tomography angiography showing non-calcified plaque in the left anterior descending artery (LAD). Massive plaque in the distal left main trunk extending from the proximal LAD (arrowheads). (G-H) Comparison of each lesion on intravascular ultrasound (G) before and (H) after directional coronary atherectomy (DCA). Resected region by DCA (arrowheads). (I-K) CAG performed at 8 months later, showing no restenosis. An asterisk indicates high lateral branch.
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Cardiovascular Society (CCS) classification 3. Coronary angiography (CAG) showed multivessel disease with a SYNTAX score of 15, including lesions in the proximal left anterior descending artery (LAD), proximal obtuse marginal branch (OM), and distal right coronary artery (RCA) (Fig. 1A-C). Considering his history of definite nickel allergy and complex multiple lesions, coronary artery bypass grafting (CABG) without the usage of metal alloy was recommended; however, the patient refused CABG and requested PCI. Coronary computed tomography angiography (CCTA) prior to PCI showed that the proximal LAD lesion consisted of a non-calcified, huge plaque in a large vessel (diameter > 3.5 mm), suggesting that it was suitable for stentless PCI with DCA/DCB angioplasty (Fig. 1D-F). DCA using Atherocut  L in four sessions with 17 total cuts (maximum cutting pressure: 4 atm) could obtain optimal lesion preparation, in which intravascular ultrasound (IVUS) showed that the percent plaque volume was successfully reduced from preoperatively 83 % to postoperatively 42 % (Fig. 1G-H). CAG, performed 8 months later, showed optimal results without restenosis, and the patient had no apparent angina symptoms for 33 months (Fig. 1I-K).
PMC9808482_02
Preoperative examination (A, B) Exercise-stress cardiac scintigraphy showing significant myocardial ischemia in the anterior part and apex of the left ventricle (yellow arrows) with total perfusion defect of 19 %. (C) Patch tests for various metal alloy show mercury, zinc, and nickel allergies (circles).
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Exercise-stress cardiac scintigraphy showed significant myocardial ischemia with a total perfusion defect of 19 % in the anteroseptal left ventricle (Fig. 2A-B). Because of the patient's metal allergy concerns based on her history of contact dermatitis to metal, we performed patch tests for various metal alloys, which showed mercury, zinc, and nickel allergies (Fig. 2C).
Multimodal images in Case 2. (A-C) Coronary angiography (CAG) showing the proximal left anterior descending artery stenosis. (D, E) Comparison of each lesion on intravascular ultrasound (D) before and (E) after directional coronary atherectomy (DCA). Resected region by DCA (arrowheads). (F-H) CAG performed at 9 months later, showing no restenosis.
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Because of the patient's strong willingness to undergo stentless PCI and her refusal to undergo CABG, an additional IVUS examination for preoperatively evaluating plaque morphology revealed a soft plaque with mild superficial calcification, which was expectedly suitable for DCA (Fig. 3A-D). DCA was performed using Atherocut  L in six sessions with 30 total cuts (maximum cutting pressure: 4 atm), which enabled the optimal reduction in plaque volume from preoperatively 78 % to postoperatively 45 % on IVUS images (Fig. 3E). The patient had an uneventful clinical course after stentless PCI, and CAG, 9 months later, showed no restenosis (Fig. 3F-H).