# Hybrid rotational atherectomy and shockwave-assisted complex left main PCI with mechanical support in a high-bleeding risk patient, a rare case report

## TL;DR

A high-risk patient with complex heart disease underwent a specialized procedure combining mechanical support and advanced techniques as an alternative to surgery.

## Contribution

A rare case report demonstrating a hybrid PCI approach using mechanical support and advanced lesion modification techniques in a high-bleeding-risk patient.

## Key findings

- Hybrid PCI with mechanical support successfully treated complex left main coronary artery disease in a high-risk patient.
- Rotational atherectomy and intravascular lithotripsy effectively addressed heavily calcified lesions.
- Optimal stent deployment was achieved using IVUS guidance, minimizing procedural risks.

## Abstract

High-risk percutaneous coronary intervention (PCI) with mechanical circulatory support has emerged as an alternative to coronary artery bypass grafting (CABG) for patients with complex left main coronary artery disease who are at high surgical risk.

A 69-year-old woman with diabetes mellitus, hypertension, hyperlipidemia, and a prior stroke presented with non-ST-segment elevation myocardial infarction. Echocardiography revealed a left ventricular ejection fraction of 25 %. Coronary angiography showed heavily calcified distal left main disease with critical ostial stenosis of the left anterior descending (LAD) and left circumflex (LCX) arteries. Deemed unsuitable for CABG, she underwent high-risk PCI with Impella mechanical support. Rotational atherectomy and intravascular lithotripsy were employed to address extensive calcification. A drug-coated balloon angioplasty was performed from the left main to the LCX, and a drug-eluting stent was placed from the left main into the mid-LAD. Post-dilation ensured optimal stent apposition and vessel patency.

Mechanical circulatory support provided essential hemodynamic stability during the complex PCI procedure. Advanced lesion modification techniques, including rotational atherectomy and intravascular lithotripsy, were crucial for treating the heavily calcified lesions, facilitating optimal stent deployment, and minimizing procedural risks.

The hybrid PCI approach combining mechanical support and advanced interventional techniques was effective in managing complex coronary artery disease in a high-risk patient contraindicated for CABG. This strategy offers a viable alternative for patients with significant anatomical and clinical challenges, emphasizing the importance of tailored therapeutic interventions in contemporary interventional cardiology.

•Hybrid Rotational Atherectomy and Shockwave PCI Approach in a high-bleeding risk patient.•Mechanical Circulatory Support in High-Risk PCI, the Impella CP device.•Alternative to CABG in a High-Surgical-Risk Patient, the complex PCI.•Optimized Stent Deployment with IVUS Guidance.•This case highlights the evolving role of hybrid PCI strategies in managing complex coronary artery diseases.

Hybrid Rotational Atherectomy and Shockwave PCI Approach in a high-bleeding risk patient.

Mechanical Circulatory Support in High-Risk PCI, the Impella CP device.

Alternative to CABG in a High-Surgical-Risk Patient, the complex PCI.

Optimized Stent Deployment with IVUS Guidance.

This case highlights the evolving role of hybrid PCI strategies in managing complex coronary artery diseases.