A62 years male ex-smoker, konwn case of Diabetes Mellitus, Hypertension, hyperlipidemia and chronic kidney diswase  Presented with inferior STEMI, Kilip 1 , referred to our centre for rimary angioplasty.Normal clinical examination.Blood test: Creatinine 144, GFR 45 and HBA1c 8.1. Other blood test were normal Echo: Normal LV size, LV EF = 53%. Regional wall motion abnormalities. 

LAD angio v.avi
RCA PPCI aspiration v.avi
FINAL PPCI RCA 1v.avi

Angiogram: LMS : Normal LAD : Moderate disease proximal , sub total occlusion mid LAD after D2 branch, LCX : Severe stenosis mid LCX , RCA : Ectatic coronaries proximal to distal , with CTO distal RCA, receiving  retrograde from LAD.PPCI RCA done, Crossed lesion with soft wire, thombus aspiration followed by Predilattion with  Emerge 2.0 x 15, Stented with  Biofreedom 3.5 x 19 and Post dilate NC Sapphire 3.75 x 15.PCI LAD IVUS guided,cfrossed lesion with Fielder XT in Finecross microcatheter, IVUS done

DCB Sequent Please Neo 2.75/40mmThen predilated with Wedge 3.0/15mmThen stented proximal to mid LAD with Biofreedom 3.0/36mmPostdilated with NC sapphire 3.5/15 subnominal mid to distal and nominal in proximalIVUS done under expansion mid stentFurther optimized with NC Sapphire 3.5/15mm at mid stent at nominal

LAd final.avi

PCI LCXlesion crossed with floppy wire, tried to pass 3.015 balloon for predilation but failed to cross, tired smalller balloons. 2.5/15 then 1.5/15 , all unable to pass  Used guideliner able to deliver smaller Ryurei 1.0 x 5mm.balloon burst at 16atm, noted staining and leakge of contrast,concealed perforation  while pulling the balloon out, the guideliner dives in deep in side the lesionbed side echo done showed no pericardial effusion, Repeat angiogram showed no stainingbedside echo -no pericardial effusion.ath this point we understand that we under estimate this clacified lesion and decided to proceed with Rota inspite of perforation riskROTABLATOR 1.75mm burr. 2 runs of 170k RPM done. One polishing run done.Further predilated with WEDGE 2.5/15mm and NC EMERGE 3.0/15mmStented with ULTIMASTER TANSEI 3.0/18mm at 9atmPost dilated with NC 3.25/15mmGood final result

Staining mid LCX noticed.avi
Rota LCX.avi
final lcx v.avi

1.      Coronary perforation is common to occur in a calcified lesion angioplasty.2. In a setting of small perforation, Rotablation can be used when the perforation is contained, as illustrated in this case3. Atherectomy devises are useful tool for proper lesion preparation to a void major complication.4. Fast decision and action when complication occurs  5. Shouldn't under estimate a calcified lesion