An IABP was inserted via contralateral femoral access for intraprocedural hemodynamic support. Given his comorbid conditions and after discussion with cardiothoracic surgery, he was deemed to be too high risk for bypass surgery, and the decision was made to proceed with percutaneous coronary intervention.

A 7F XB LAD 4 guiding catheter engaged the left main coronary artery. A standard 0.014 guidewire was advanced to the distal LCx lesion, and balloon angioplasty was performed. The LCx was then treated with two 2.5 × 12 mm tents that were deployed and post-dilated with a 2.75 NC balloon at high pressure (Figs. 18.3 and 18.4). The 0.014 guidewire was then directed into the LAD. The 0.014″ guidewire was then exchanged for a 0.009″ rota extra-support wire using a Corsair support catheter (Fig. 18.5). At this point, rotational atherectomy was performed, initially with a 1.25 mm burr at 150,000 RPM, then a 1.5 mm burr, and finally a 1.75 mm burr (Fig. 18.6). Scoring atherectomy of the LAD was performed using a 2.0 and a 2.5 angiosculpt balloon. Next, a 2.75 × 28 DES was deployed in the distal left main and into the proximal LAD, following in overlapping fashion with a 2.25 × 28 mm DES, and a 2.25 × 16 mm DES was deployed most distally, with stents post-dilated under high pressure (Fig. 18.7). Next, a 3.5 × 33 mm DES was deployed to the left main coronary artery and post-dilated with a 4.0 × 15 mm and then a 4.5 × 15 mm noncompliant balloon (Fig. 18.8). Final angiographic images showed excellent results (Fig. 18.9).