This document discusses three cases of complex multivessel percutaneous coronary intervention (PCI) involving the left main coronary artery. Case 1 involves PCI of a severe ostial left main lesion in a patient with end-stage renal disease. Intravascular imaging guided planning and a cutting balloon was used to treat superficial calcium. Case 2 involves a patient with three vessel disease, distal left main involvement, and high surgical risk. Atherectomy and lithotripsy were used in addition to stents to treat complex lesions. Case 3 involves a frail elderly patient where single access PCI via Impella was complicated by tortuous vessels. Intravascular imaging and occlusion balloons were useful for bifurcation treatment. The importance

1. Left Main and Multivessel PCI
Arasi Maran MD, FSCAI, FACC
Associate Professor of Medicine
Director of Coronary CTO Program
Medical University of South Carolina
Ralph H Johnson VA Medical Center
Charleston SC

2. Within the past 12 months, I or my spouse/partner have had a
financial interest/arrangement or affiliation with the organization(s)
listed below.
Affiliation/Financial Relationship Company
Consulting Fees/Honoraria Boston Scientific, Teleflex,
Medtronic, Shockwave
Disclosure Statement of Financial Interest
Faculty disclosure information can be found on the app

3. Case 1
• 77yr old with ESRD, Chest Pain during HD
• NSTEMI with normal EF, mild AS
• LHC – Severe ostial Left main
• CT Surgery – 25% mortality with ESRD
• Came back to the cath lab

4. DIAGNOSTIC CATH

5. IVUS

6. PCI - Plan
Femoral access
– issues with
left main
engagement
Wolverine
Cutting balloon
NC Balloon
IVUS Stent IVUS

8. 3.5 Wolverine
4.0 NC Balloon

9. Post Wolverine and NCB

10. Stent Placement

11. 4.0 Megatron

14. Conclusions for Case 1
• Intravascular imaging is key to plan for a complex case
• Not technically complex, but hemodynamics can get tricky
• Wolverine is a great tool for managing superficial calcium,
ostial disease
• Trust intravascular imaging and Hemodynamics

15. Case II
49 yr old WM with
H/O Recurrent
Necrotizing
Pancreatitis
Disconnected
Pancreas with
Pancreatic stent
in place
H/O Alcohol
abuse
Chronic Kidney
disease
NSTEMI
presentation
3 V disease
CT Surgery
Turndown

16. Labs
4/2022
Echo: 4/11/2022 <20%
Bun/Cr -30/1.5, eGFR >60
BNP 2278
HbA1 C 7.0
• Evaluated in 6/2022
• Started on DAPT
• On GDMT

21. Discussion
Distal Left Main
Long LAD lesion
Long Cx Lesion
Calcium
Low EF
High risk of bleeding
Short DAPT
• MCS
• Atherectomy choice
• Access
• Stent strategy

22. My Plan
RHC
MCS based on
numbers
IVUS
SWL if balloon
delivers
If not
atherectomy
Double Stent
Strategy for Left
Main Bifurcation

23. Swan Numbers:
CO/CI:
TD- 4.27/2.11
Fick- 3.57/1.77
Pa sat- 45%

24. • Access – 6/7 Fr
Terumo sheath
• Guide: 7 Fr
EBU 3.75
• LAD wire –
Runthrough
• IVUS – could
not cross

25. 1.75 Burr

27. 2.75x20 & 3x30 DES
Circumflex
3x12 SWL

29. • 3x20 NC
Balloon

30. 3x12 SWL
3x230NC

31. Mid LAD 3x38
Left Main to mid LAD 4x38

32. Kiss POT

33. Final Angiogram

34. FU Echo in 3 mos – EF – 42%

35. Conclusions
Follow Hemodynamics
Jumping to Highest
MCS is not ‘latest’
anymore
Combining strategies –
Atherectomy, Cutting
balloon & Lithotripsy

36. Case III
• 91yr old with 87yr old wife to clinic to discuss PCI options
• Worsening dyspnea on exertion and LE edema
• PMH: Atrial fibrillation, Asthma, Tobacco abuse
• Echo and Coronary Calcium score -1655---LHC
• Meds: Aspirin , Atorvastatin, Lopressor 25 mg BID, Warfarin,
Inhalers

38. Vital Signs
135/102/23
-----------------
4.4/ 25 /1.2
BP = 150/94
O2 Sat – 100%
Ht -6 Fr Wt – 72 Kg

39. Echo
EF of 72%
Severe biatrial
enlargement
AVA -1.1sq cm
Mean gradient
of 14. mm of
Hg
Max pg - 27
Peak velocity
of 2.61m/s
Moderate TR,
RVSP – 36 mm
of Hg

43. Factors To Consider
• Poor visualization of the bifurcation
• Need for atherectomy in the setting of HR of 45 BPM
• Moderate AS
• Normal EF
• Frailty

44. Single access
Impella CP
6/7 Terumo sheath
7 Fr EBU 3.5

45. Extremely
tortuous iliacs
Dilated aorta
Very tight/guide-
kinks

61. Take Home Points
• Iliac tortuosity can be a major issue with single access via
Impella sheath
• Intravascular imaging
• Shockwave Lithotripsy can be used to modify plaque at
bifurcation points
• Occlusion balloon technique is extremely useful to wire vessel
take off at difficult angles
• Sometimes – walk away with the simplest strategy

62. Cautionary Tale
• 59yr old
• Indian male
• Works in our hospital
• Typical Angina
• Stress Test – Anterior ischemia
• Normal EF
• Known Elevated Ca Score

63. Cautionary Tale

64. Cautionary Tale

65. Final Take Home Points – Left Main/Multivessel
PCI
• Failing to Planning = Planning to fail
• Review – Alone, With another partner, Find another partner
• Make Plan A
• Then make plan B and then Plan C
• Figure out your back up person
• Do not forget your documentation – risk benefit ratio, alternate
treatment options

66. It is Okay
• Despite your best efforts,
outcome was devastating if
• You did it for the right
reason
• You have done due
diligence
• You learn from what you
missed.

67. Thank You
• maran@musc.edu
• @arasimaran
• 843-303-1897