PCI was performed via a right femoral 7 Fr EBU 3.0 guide. LCX wiring was extremely challenging due to a large ostial aneurysm and discrete stenosis; reverse wiring failed, so the LAD was treated first. Using a Caravel microcatheter, an extra-support Rotawire was advanced, and sequential 1.25 mm and 1.75 mm burr atherectomy was done for LAD and LM–LAD segments. A 2.0 mm burr was avoided due to iliac angulation. After adequate LAD preparation, LCX wiring succeeded with a Suoh 03 wire, exchanged for a Rota Extra Support wire via Caravel. LM–LCX ostium was ablated with 1.25 and 1.75 mm burrs, though the burr could not enter LCX proper.

Suboptimal balloon dilation led to implantation of a 2.75 × 8 mm Onyx DES at the LCX ostium. The LAD was predilated and treated with 2.0 × 38 mm and 2.5 × 38 mm Xience Sierra stents plus a 3.5 × 15 mm Megatron for LM–LAD. IVUS confirmed full stent expansion and apposition with no residual stenosis. A minor LAD ostial type II dissection was observed but without flow limitation.

Final angiography showed excellent patency. ECMO was removed uneventfully, and manual hemostasis achieved due to femoral aneurysms precluding device closure.