HDLC 44;LDLC 101;GLU 93; HBA1C5.5; CREA 0.9;AST 19;ALT 13Echocardiography showed Mid-reducedLVSF with EF: 40%, Mild MR, Hypokinesiaof anterior wall, and PAP: 27mmHg

LM: D/3:discrete 99% stenosis, Medina (1,0,0) with LAD and LCxLAD: heavycalcificationP/3 to M/3: Diffuse60-95% stenosis, Medina (1,1,0) with DB1 (aneurysm formation over ostium)D/3: Diffuse 60-70% stenosisP/3 to M/3 of DB1: Tubular 70-80%stenosisLCx: Patentand non-dominant vesselRamus Intermedius : Ostium to M/3: Diffuse 70-95% stenosisRCA: calcificationD/3: Diffuse 70-80% stenosis P/3 of PDA: Discrete 60-70% stenosisGiving collateral flow to septalperforator



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1. V-A mode ECMO was used for CHIP PCI2. 1.5mm balloon was advanced to m-LAD3. 2.0mm balloon failed to cross the heavycalcified lesion at m-LAD4. By Extra support rota wire, 1.25mm Burradvanced to the lesion in a slow and steady manner (163300-182000 rpm). p-LADlesion was polished, however, Burr could not pass through m-LAD tortuous andheavy calcified bifurcation lesion. To avoid high risk of perforation, weterminated the Rotational Atherectomy5. 1.5mm balloon was advanced to m-LADlesion6. 2.0 balloon failed to deliver to the M/3LAD tortuous and heavy calcified bifurcation lesion, even under 5.5 FrGuideLiner or Buddy wire technique7. 2.0mm balloon was advanced to m-LAD throughDB wire, inflated at pressure 22-24 atm8. 2.0mm Cutting balloon was advanced tothe lesion through DB wire, inflated at pressure 6-18 atm9. 2.0mm balloon was advanced to the lesionthrough DB wire10. A 2.0 balloon successfully advanced to mto d-LAD11. 2.0mm Cutting balloon was advanced tothe lesion through LAD wire, inflated at pressure 8-18 atm12. 2.5mm balloon was advanced to m-LADlesion13. 2.0x30mm Onyx stent failed to adavnceto the lesion, even under GuideLiner 6Fr14. Finally 2.0x30mm Onyx stentsuccessfully advanced to the proper segment at m-LAD under Wiggle wire support15. 2.5x28mm Xience Sierra stent wasdeployed at p-Ramus16. 2.75x30mm Onyx stent was deployed at LMto m-LAD17. Final angiography showed TIMI 3 distalflow & No extravasation



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*. Critical LM disease with longcalcified lesion may need more procedure time, prophylactic MCS should beconsidered*. Rotational atherectomy in Angulatedand calcified lesion should be carful with complication, half-way rotationalatherecmoy should be considered*. Angulated and calcified lesion, usingCutting and NC balloon could be an another choice to modified lesion. If a bigside branch (diameter > 2.5mm) after angulated and calcified lesion may be anotherway to modified plque.*. Provisional stenting technique inbifurcation should be a first choice to make procedure simple and saveprocedure time