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This month, we present the case of an 80 years old male patient, smoker, known to have HFrEF secondary to a cardiac amyloidosis TTR s/p CRT-D, severe aortic stenosis (ASA 0.6 cm2), hypertension, dyslipidemia and chronic kidney disease.

Coronary angiography pre-TAVR revealed: dominated RCA that is occluded as well as a moderate lesion of the obtuse marginal and severely calcified lesions of the proximal and mid LAD that is occluded distally.

Educational objectives

  • How to manage a high-risk patient with multiple co-morbidities.
  • Plan a step-by-step approach procedure for calcified lesion preparation and stenting.
  • Choice of material: introducer size, guidewires, guide extension, choice of lesion modifying technique/tools.
  • Role of intravascular imaging.

Step-by-step procedure:

1) Access site and hemodynamic stability:

  • Right radial approach: 7 French EBU 3.5 to the left main.
  • Under Dobutamine IV infusion.
  • Anticoagulation using heparin.

2) Intravascular imaging:

  • Two 0.014” Sion Blue (Asahi) guidewires for extra support were introduced into the LAD.
  • Intravascular imaging using optical frequency domain imaging (OFDI) (Terumo) at 40 mm/sec in order to minimize contrast injection showed superficially calcified LAD with several calcified nodules at the mid-LAD level and 360° calcium rings.

3) Calcium modifying device:

  • Intravascular lithotripsy using a 3.5 x 12 mm Shockwave balloon was selected and the mid-LAD and proximal LAD lesions were predilated.
  • Upon balloon inflations, a drop of blood pressure was noted, a small dose of Noradrenaline was set up.
  • Further lesion preparation using a non-compliant balloon 3.5 mm inflated up to 20 atm was done at the level of the mid and proximal LAD lesions.

4) LAD stenting:

  • A 3.5 x 21 mm Nagomi Ultimaster (Terumo) stent could not cross the proximal LAD lesion.
  • A 6 French (due to out-of-stock 7 French) Boosting guide extension catheter (QX Medical) was introduced to the mid-LAD and facilitated stent delivery to the mid-LAD lesion that was inflated to 16 atm.
  • Using the stent balloon, the guide extension catheter was advanced into the recently implanted stent.
  • A 4.0 x 33 mm Nagomi Ultimaster (Terumo) was then implanted to cover the proximal LAD lesion and inflated to 16 atm.

5) Stent optimization:

  • An OFDI run was performed at this time in order to assess the implanted stents and showed stent malapposition at different levels as well as a small dissection.
  • Post-dilatation of the distal stent using a 4.0 mm non-compliant balloon inflated at 20 atm followed by a post-dilatation of the proximal stent using a 4.5 mm non-compliant balloon inflated at 20 atm were performed.
  • The angiographic end-result was perfect.

6) Post-procedure patient care:

  • Dobutamine tapering to stop over the next hour.




1. Kubo, T.; Shinke, T.; Okamura, T.; Hibi, K.; Nakazawa, G.; Morino, Y.; Shite, J.; Fusazaki, T.; Otake, H.; Kozuma, K.; et al. Optical Frequency Domain Imaging vs. Intravascular Ultrasound in Percutaneous Coronary Intervention (OPINION Trial): One-Year Angiographic and Clinical Results. Eur. Heart J. 2017, 38, 3139–3147, doi:10.1093/eurheartj/ehx351.
2. Kereiakes, D.J.; Ali, Z.A.; Riley, R.F.; Smith, T.D.; Shlofmitz, R.A. Intravascular Lithotripsy for Treatment of Calcified Coronary Artery Disease. Interv. Cardiol. Clin. 2022, 11, 393–404, doi:10.1016/j.iccl.2022.02.004.
3. Higami, H.; Matsuda, H.; Tateyama, H.; Suzuki, Y.; Kaitani, K. Effect of Crack Patterns in Calcified Plaque on Lumen Area after Stenting for a Severe Calcified Coronary Artery (from the Optical Frequency Domain Imaging-Guided Percutaneous Coronary Artery Intervention for Calcified Lesion Registry). J. Interv. Cardiol. 2022, 2022, doi:10.1155/2022/7821956.
4. Caiazzo, G.; Di Mario, C.; Kedhi, E.; De Luca, G. Current Management of Highly Calcified Coronary Lesions: An Overview of the Current Status. J. Clin. Med. 2023, 12, doi:10.3390/jcm12144844.
5. De Maria, G.L.; Scarsini, R.; Banning, A.P. Management of Calcific Coronary Artery Lesions: Is It Time to Change Our Interventional Therapeutic Approach? JACC Cardiovasc. Interv. 2019, 12, 1465–1478, doi:10.1016/j.jcin.2019.03.038.
6. Shlofmitz, R.A.; Galougahi, K.K.; Jeremias, A.; Shlofmitz, E.; Thomas, S. V.; Ali, Z.A. Calcium Modification in Percutaneous Coronary Interventions. Interv. Cardiol. Clin. 2022, 11, 373–381, doi:10.1016/j.iccl.2022.06.001.



Shooting date : 2024-02-05
Last update : 2024-03-22

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Complex CTO: Ostial LAD CTO with ambiguous Proximal CAP

Case of the month: May 2019

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