Hybrid rotational atherectomy and shockwave-assisted complex left main PCI with mechanical support in a high-bleeding risk patient, a rare case report

Introduction

High-risk percutaneous coronary intervention (PCI) with mechanical circulatory support has emerged as an alternative to coronary artery bypass grafting (CABG) for patients with complex left main coronary artery disease who are at high surgical risk.

Case presentation

A 69-year-old woman with diabetes mellitus, hypertension, hyperlipidemia, and a prior stroke presented with non-ST-segment elevation myocardial infarction. Echocardiography revealed a left ventricular ejection fraction of 25 %. Coronary angiography showed heavily calcified distal left main disease with critical ostial stenosis of the left anterior descending (LAD) and left circumflex (LCX) arteries. Deemed unsuitable for CABG, she underwent high-risk PCI with Impella mechanical support. Rotational atherectomy and intravascular lithotripsy were employed to address extensive calcification. A drug-coated balloon angioplasty was performed from the left main to the LCX, and a drug-eluting stent was placed from the left main into the mid-LAD. Post-dilation ensured optimal stent apposition and vessel patency.

Discussion

Mechanical circulatory support provided essential hemodynamic stability during the complex PCI procedure. Advanced lesion modification techniques, including rotational atherectomy and intravascular lithotripsy, were crucial for treating the heavily calcified lesions, facilitating optimal stent deployment, and minimizing procedural risks.

Conclusion

The hybrid PCI approach combining mechanical support and advanced interventional techniques was effective in managing complex coronary artery disease in a high-risk patient contraindicated for CABG. This strategy offers a viable alternative for patients with significant anatomical and clinical challenges, emphasizing the importance of tailored therapeutic interventions in contemporary interventional cardiology.