PMC10442179_01
Coronary angiography and PCI of RCA. Coronary angiography revealed severe stenosis with heavy calcification in the proximal and middle portions of the RCA (a) and in the bifurcation of the LMT (b-d). The calcified lesion could not be dilated with a 2.0-mm semi-compliant balloon (e) and was successfully dilated with a 2.0-mm Scoreflex  scoring balloon (f), followed by implanting with 3.5-mm x 28-mm and 4.0-mm x 28-mm sirolimus-eluting stent of Ultimaster Tansei  (g and h), successfully resulting in good dilatation (i).
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Coronary angiography was performed to investigate the cause of the left ventricular dysfunction, which revealed severe stenosis with heavy calcifications in the proximal and middle portions of the right coronary artery (RCA) and the bifurcation of the left coronary main trunk (LMT; Figures 1(a), 1(b), 1(c), and 1(d)). First, PCI was performed on the RCA (Figures 1(e), 1(f), 1(g), 1(h), and 1(i)) via the left femoral approach. A 2.0-mm semi-compliant balloon failed to dilate the calcified lesion (Figure 1(e)), but a 2.0-mm scoring balloon (Scoreflex , OrbusNeich, Hong Kong, China) successfully dilated the stenotic lesion by pressurizing it to 30 atm (Figure 1(f)), followed by dilation using a 3.5-mm high-pressure balloon and implantation with 3.5-mm x 28-mm and 4.0-mm x 28-mm sirolimus-eluting stent of Ultimaster Tansei  (Terumo Corp., Tokyo, Japan; Figures 1(g) and 1(h)), successfully resulting in adequate dilatation without hemodynamic compromise (Figure 1(i)). For the heavily calcified lesion in the LMT, there was a concern that it would result in stent under-expansion and an increased risk of future restenosis without rotational atherectomy.
Impella-supported OCT-guided rotational atherectomy for LMT bifurcation lesion. The heavy calcification at the bifurcation of the left main coronary artery was visible on fluoroscopy (a). Coronary angiography before PCI (b and c). Rotational atherectomy with a 1.5-mm RotaPRO  was performed from the LMT to the proximal LAD artery (d) and proximal left circumflex artery (LCx) (j). OFDI images pulled back from LAD (e-i). Then, additional atherectomy was performed from the LMT to the proximal LCx (k) and LAD (l) using a 2.0-mm RotaPRO , and the lesions were again observed by OFDI, confirming that the calcified plaque had sufficiently reduced in volume (m-r).
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The heavy calcification at the bifurcation of the left main coronary artery was visible on fluoroscopy (Figure 2(a)). Because the optical frequency domain imaging (OFDI) catheter could not pass through the lesions, rotational atherectomy with a 1.5-mm RotaPRO  (Boston Scientific Corp., Marlborough, MA, USA) with RotaWire Extrasupport  (Boston Scientific Corp.) at 200,000 rpm was performed from the LMT to the proximal left anterior descending (LAD) artery and proximal left circumflex artery (LCx; Figures 2(d) and 2(g)), and then each lesion was observed via OFDI (Terumo Corp.). However, some remained as entire circumferential calcified plaques with a maximum thickness of 1.5 mm (Figures 2(f), 2(g), 2(g), 2(h), and 2(i)). Next, additional atherectomy was performed from the LMT to the proximal LCx and LAD using a 2.0-mm RotaPRO  (Figures 2(j) and 2(m)). The lesions were again observed via OFDI, confirming that the calcified plaque had sufficiently reduced in volume (Figures 2(m), 2(n), 2(o), 2(p), 2(q), and 2(r)).
Double-kissing culotte stenting for LMT bifurcation lesion. After dilation with a 3.0-mm high-pressure balloon from the proximal LCx to the LMT (a), a 3.0-mm x 28-mm Ultimaster Tansei  stent was implanted from the LMT to the proximal LCx (b). KBI was performed with 3.5- and 3.0-mm balloons (c). A 3.5-mm x 24-mm Ultimaster Tansei  stent was implanted from the proximal LAD to the LMT (d), followed by a proximal optimization technique with a 4.5-mm balloon in the LMT (e), and KBI was performed with 3.5- and 3.0-mm balloons (f). A 3.5-mm x 18-mm stent of Ultimaster Tansei  was implanted in the distal portion of proximal LAD (g). Coronary angiography (h and i) and OFDI images (j-l) confirmed good flow and good dilatation of lesions.
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After dilation using a 3.0-mm high-pressure balloon from the proximal LCx to the LMT (Figure 3(a)), a 3.0-mm x 28-mm Ultimaster Tansei  stent was implanted from the LMT to the proximal LCx (Figure 3(b)). Then, after recrossing the guidewire into the LAD, kissing balloon inflation (KBI) was performed using 3.5- and 3.0-mm balloons (Figure 3(c)). Then, a 3.5-mm x 24-mm Ultimaster Tansei  stent was implanted from the LMT to the proximal LAD (Figure 3(d)), followed by a proximal optimization technique using a 4.5-mm balloon in the LMT (Figure 3(e)), recrossing the guidewire to the LCx. Again, KBI was performed using 3.5- and 3.0-mm balloons (Figure 3(f)), a procedure previously reported as the double-kissing culotte technique. Thereafter, a 3.5-mm x 18-mm stent of Ultimaster Tansei  was implanted in the distal portion of the proximal LAD (Figure 3(g)). Coronary angiography and OFDI images confirmed good flow and good dilatation of lesions (Figures 3(h), 3(i), 3(j), 3(k), and 3(l)).