An 82-year-old woman (BMI 26 kg/m²) presented with several weeks of typical exertional chest tightness that was refractory to antianginal therapy. Her past medical history included type 2 diabetes mellitus, hyperlipidemia, and hypertension. She denied any smoking or family history of premature coronary artery disease.

Chest radiography showed no evidence of heart failure. Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 60% with no regional wall-motion abnormalities and no significant valvular heart disease. A myocardial perfusion scan revealed reversible ischemia, suggestive of underlying obstructive coronary artery disease.

Catheterization revealed a 95% distal left main stenosis with a calcified nodule protruding into the LAD and LCX ostia, a 99% proximal LAD lesion with an additional 90% stenosis after the first diagonal branch, non-critical LCX disease, and a 70% proximal RCA lesion with multiple critical PDA stenoses. The patient and family declined PCI in the cath lab, with a Syntax score of 40.


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Impella support was established before the procedure. The LCA was engaged with an EBU 3.0 × 7 Fr guide, and a SUOH-03 wire was advanced into the LCX. A 2.0 × 20 mm balloon was inflated across the very tight LM–LCX lesion, but IVUS still could not cross, so rotablation was performed first. The SUOH-03 wire was exchanged for a Rota Floppy using a Caravel microcatheter, and a 2.0 mm burr successfully ablated the heavily calcified, angulated LM–LCX segment.After calcium modification, a Fielder FC wire was advanced into the LAD using a reverse-wire technique. Severe mid-LAD calcification required switching to a Rota Floppy wire, and a 1.25 mm burr was used for LAD rotablation. Bradycardia occurred during Rota, so a temporary pacemaker was inserted. A 2.25 × 15 mm NC balloon was then inflated to 12 atm to further prepare the LAD.The LAD was stented with an Onyx 2.25 × 22 mm DES (6–16 atm) and subsequently crushed with a 3.5 × 12 mm NC balloon. LM–LCX was stented with an Onyx 3.5 × 15 mm DES (11–12 atm). LAD was rewired with a Sion Blue supported by a Crusade dual-lumen catheter, and stent struts were opened using 1.5 × 10 mm and 2.5 × 15 mm balloons. LAD-P was post-dilated with a 2.5 × 15 mm NC (10 atm), and LM–LAD with a 2.5 × 15 mm NC (12–18 atm). Final kissing inflation with a 3.5 × 12 mm NC and 2.5 × 15 mm NC balloons achieved optimal flow.The Impella was removed under stable hemodynamics, and the access site was closed with two Perclose devices without bleeding.



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