Case 3: Unknown defect in the proximal LMT (Severe calcified nodule in the proximal LMT)
A 76-year-old male had presented with chest pain with left shoulder radiation and shortness of breath to outside hospital one week ago. The patient was found to have elevated troponin-I HS (peak 16.8 ng/L), and subsequent coronary angiography showed multi-vessel coronary artery disease. He had a history of hypertension, ESRD (on dialysis), dilated cardiomyopathy, PAF, and CAD (status post PCI, details unknown). Cardiothoracic surgery was consulted for possible CABG, but he declined and is opting for PCI revascularization. He transferred to our hospital for high-risk PCI. Echocardiography showed reduce left ventricular wall motion with ejection fraction of 30%. We planned for impella-assisted PCI.
Angio Pre CAU run5
IVUS 3 Pre just LM
Coronary angiography showed 80-90% stenosis at the ostial LMT with spherical perspective image and 80-90% stenosis at the proximal LAD. The LCX had a moderate 50-60% stenosis at OM1. RCA had a mid 70-80% stenosis. IVUS images showed severe calcified nodule at the ostial LMT, although IVUS catheter did not pass the proximal LAD lesion. The MLA was 6.18mm². Therefore, we first performed rotational atherectomy (RA) with a 1.25mm burr for proximal LAD and a 2.0mm burr for ostial LMT.
IVUS 11 Post RA2.0 just LM
Then, the proximal LAD and ostial LMT lesion were pre-dilated with 3.0mm non-compliant (NC) balloon. Repeat IVUS showed fractures of calcified plaque.
IVUS After RA+POBA run19
A 3.0mm x 38mm DES was deployed at the proximal LAD and two 5.0mm x 8mm DES was deployed at the ostial LMT. Repeat IVUS showed stent proximal edge dissection and stent malapposition at the proximal LAD.
IVUS 29 Post Stent from LAD to LM
Therefore, another 3.5mm x 16mm was deployed at the proximal LAD to overlap the first stent. Then stents was post-dilated with a 3.5mm NC balloon for the proximal LAD and a 5.0mm NC balloon for the ostial LMT. The MSA were 10.5mm² for proximal LAD and 20.8mm² for ostial LMT.
Angio Post CRA run46
In this case, it was not clear from the angiogram whether the circular defect in the ostial LMT was a thrombus or calcification, but by using IVUS, it was identified as a calcified nodule, and appropriate treatment was achieved using rotational atherectomy. In addition, we were able to identify the dissection of the stent edge at the proximal LAD, which allowed us to appropriately bail out by deploying another stent.