PMC9856338_01
Intravascular ultrasound demonstrating stenosis of the ostial LCX: (A) distal LCX with diffuse, punctate calcification; (B) ostial LCX stenosis with heavy calcification covering 270  of the vessel circumference and minimal lumen area of 1.8 mm2; (C) left main. Setup of CorPath GXR System: (D) robotic console with a guiding catheter placed in the right radial artery; (E) remote control station. Procedural angiograms: (F) Diagnostic angiography; (G) Spider view showing lesion preparation with intravascular lithotripsy balloon (3.5/12 mm) with wires in LAD and LCX inflated; (H) DES implantation into the left main and LCX; (I) kissing-balloon maneuver with 3.0/15 mm each balloon; (J) proximal optimization in the left main coronary artery with 4.5/12 non-compliant balloon; (K) final procedural result.
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Intravascular ultrasound (IVUS) of the LCX to LM showed a minimal lumen area of 1.8 mm2 of the ostial LCX with a distal reference vessel diameter of 3.7 mm and severely eccentric stenosis showing a 270  arc of calcium (Figure 1A-C). The decision of the local heart team was to use rPCI (CorPath GXR, Corindus Inc., Natick, MA, USA) (Figure 1D and E) with addition of IVL (Shockwave Medical, Inc., Santa Clara, CA, USA) to allow high-precision, thorough lesion preparation followed by a provisional stent strategy. The LM was intubated manually with an EBU 3.75 (Medtronic, Dublin, Ireland) (Figure 1F) using a radial approach. A total of 7 cycles at 80 Hz were applied (Figure 1G). The balloon-expandable stent was inflated to 14 atm for 15 sec (Figure 1H). After robotically assisted rewiring of the LAD through the distal stent struts of the implanted stent (see Supplementary material online, Video S3), a kissing-balloon maneuver was performed (both balloons: NC Emerge 3.0/15 mm, Boston Scientific) (Figure 1I). The procedure was finalized with a proximal optimization technique using a non-compliant balloon (NC Emerge 4.5/12 mm, Boston Scientific) that was inflated to 12 atm in the distal LM (Figure 1J). The final angiography and manually performed IVUS (Minimal lumen area [MLA] LM: 13.2 mm2; MLA ostial LCX: 7.5 mm2) showed a good stent result (Figure 1K).