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Case 4: LM bifurcation lesion with calcified nodule and ulcerated plaque

Case Presentation

An 81-year-old male with progressive worsening DOE was admitted to an outside hospital with hypertensive crisis and pulmonary edema. After coronary CTA showed 3V CAD with positive CT-FFR, he was referred to our hospital for further coronary assessment. Patient’s history included hypertension, NIDDM, and hyperlipidemia. Echocardiography showed normal left ventricular wall motion with ejection fraction of 60%.

CAG showed 70-80% stenosis at the distal LM, 70-80% stenosis at the proximal and mid LAD, and 80-90% stenosis at the proximal LCX. IVUS images showed ulcerated plaque and calcified nodule in the LM. In addition, there was a moderate-severe calcified plaque in the proximal LAD and proximal LCX. The mid LAD could not be observed by IVUS due to inability of IVUS catheter to cross the lesion, but angiographic findings were suggestive of severe calcification. The MLA was 3.7mm2, 3.5mm2, and 3.1mm2 for the LM, LAD, and LCX on IVUS, respectively. Based on the findings, we decided to perform lesion modification with a rotational atherectomy before stenting. Ablation was performed with a 1.5mm burr for the mid LAD and a 1.75mm burr for the proximal LAD, proximal LCX, and LM.

Angio Pre



After RA, the mid LAD lesion was pre-dilated with 3.0mm non-compliant (NC) balloon, and a 3.0mm x 33mm DES was deployed. The stent was post-dilated with 3.0mm NC balloon up to 24 atm. Subsequently, lesion in the LM distal and proximal LCX were pre-dilated with 3.5mm NC balloon and lesion in the proximal LAD was pre-dilated with 3.0mm NC balloon. Then 3.5mm x 18mm DES and 3.5mm x 8mm DES were placed across the proximal LAD and proximal LCX respectively using mini-crush technique. KBI were performed with 3.5mm and 3.0mm NC balloons. The final MSA were 16.6mm2, 10.9mm2, and 7.4mm2 for LM, LAD, and LCX, respectively.


IVUS post LCx-LM

Final angio

In this case, IVUS imaging detected a calcified nodule, ulcerated plaque and moderate-severe calcification resulting in the use of rotational atherectomy. After stent deployment, IVUS confirmed optimal stent expansion and apposition.


Left Main DK Crush Video ID