Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS...
-
Upload
claire-booker -
Category
Documents
-
view
222 -
download
3
Transcript of Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS...
![Page 1: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/1.jpg)
Calcified Coronary Lesion:
Difficulties and Challenges
Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS
Beijing An Zhen Hospital, Capital Medical University, Beijing, China
![Page 2: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/2.jpg)
Sweet dream or nightmare ?
![Page 3: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/3.jpg)
Marker for CAD and increased mortality
JACC: CARDIOVASCULAR IMAGING. 2010 Dec;3(12). JACC: CARDIOVASCULAR IMAGING. 2012 Oct;5(10)
4,425 Suspected CAD patientsFollow-up 3 years
4,609 asymptomatic individuals Follow-up 3.1 years
![Page 4: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/4.jpg)
Coronary Artery Calcium (CAC) in the Multi-Ethnic Study
Coylewright et al. Atherosclerosis.2011
CAC are associated with CHD events
![Page 5: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/5.jpg)
Risk Factors ( The MESA study )
Race and gender
Age
BMI
Smoking
Family history of heart attack
Hyperlipidemia Intimal calcification
Hypertension Intimal calcification
Diabetes Medial calcification
CKD Medial calcification
Rheumatic diseases
Circulation. 2007;115:2722-2730
![Page 6: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/6.jpg)
Inverse relationship between BMI and CAC
Atherosclerosis. 2012 March ; 221(1): 176–182.
Method :9,993 patients undergoing PCIThe degree of index lesion calcification (ILC) based on angiography
![Page 7: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/7.jpg)
Elevated BSA is a predictor of CAC, not BMI
Coron Artery Dis 2012 Mar;23(2):113-7
Method : 3172 consecutive patients underwent CAC scores
![Page 8: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/8.jpg)
Mechanism of CAC
Vascular calcification is an active ,regulated process
BMP-Wnt signalingBMP-Smad signaling
![Page 9: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/9.jpg)
Major Theories of Vascular Calcification
Vascular calcification
Apoptotic bodies
CELL DEATH
LOSS OF INHIBITIONPyrophosphateMGPOPNFetuin/alpha2-HS glycoproteinOthers
Matrix Vesicles
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
BisphosphonatesOPG
Bone Remodeling
CIRCULATING NUCLEATIONAL COMPLEXES
Ca x Pi
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
Apoptotic bodies
Matrix Vesicles
INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
CELL DEATH
BisphosphonatesOPG
Apoptotic bodies
Matrix Vesicles
INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
CIRCULATING NUCLEATIONAL COMPLEXES
CELL DEATH
BisphosphonatesOPG
Apoptotic bodies
Matrix Vesicles
INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
Bone Remodeling
CIRCULATING NUCLEATIONAL COMPLEXES
CELL DEATH
BisphosphonatesOPG
Apoptotic bodies
Matrix Vesicles
INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells
DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia
INDUCING FACTORSPiLipidsInflammatory cytokinesOthers
![Page 10: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/10.jpg)
No effective medicine treatment
• Evidence from meta-analysesStatin and LDL-C
Statin and calcification
Coylewright et al. Atherosclerosis.2011
![Page 11: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/11.jpg)
Statins promote CAC (VADT trail)
Saremi et al. Diabetes Care.2012;2390-2
![Page 12: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/12.jpg)
Stent thrombosis12
![Page 13: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/13.jpg)
Strategy of PCI in CAC
Balloon angioplastyCutting balloonRotablatorStentPost dilationLaser
![Page 14: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/14.jpg)
Strategy for balloon angioplasty
Small size balloon preferedPressure of BC from 8 atm, slowly increase The up limit of pressure may be 16 atmFlow restricting dissection or perforation be
concerned
14
![Page 15: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/15.jpg)
Cutting balloon for calcified lesion
• Indication for cutting balloon: Lesion relatively short (<20mm) Concentric lesions • Heavily calcified lesion not appropriate, but
sometimes brought supprise
15
![Page 16: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/16.jpg)
Rotablator for calcified lesion
Effective device for calcified lesionDifferential tissue cutting ----selectively hard lesion, no soft tissueOptimal burr size---60%-70% of reference vessel
diameter Prevent no flow & slow flow ----nitroprusside, adenosine , etcUpper limit of rotablator: just enough for
revascularization
16
![Page 17: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/17.jpg)
Rotational Atherectomy(RA)
JACC Cardiovasc Interv 2013 Jan;6(1):10-9
Randomized ROTAXUS Trial Outcome
![Page 18: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/18.jpg)
Randomized ROTAXUS Trial Outcome
Death MI
TVR MACE
JACC Cardiovasc Interv 2013 Jan
CONCLUSIONS :
RA does not increase the efficacy of DES in calcified lesions
Using RA did not reduce late lumen loss of DES at 9 months
RA remains the default strategy for complex calcified lesions
![Page 19: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/19.jpg)
Analysis of the UK central cardiac audit database
Method :221,669 PCI procedures 2152 patients (0.97%) : RA (RA+) Remainder conventional PCI : (RA-)
CONCLUSIONS :RA was undertaken in patients with higher pre-procedural risk. Medium term survival was worse among patients undergoing RA.Procedural success and complication rates seem acceptable in this context. RA remains clinically useful for patients with calcified coronary lesions.
Int J Cardiol. 2014 Jan 1;170(3):381-7
![Page 20: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/20.jpg)
Rotational atherectomy for LM in octogenarians 42 patients ≥80 years had undergone stenting for calcified LMCA
disease Procedural success is good (92.3% vs. 96.6%) RA appeared to be a safe and effective strategy for the treatment of
LMCA disease in octogenarians who were refused for surgery
Int J Cardiol 2013 Apr;26(2):173-82
![Page 21: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/21.jpg)
Rotablator for failed angioplasty • An 84 year man• Previous failed angioplasty due to balloon rupture• CAG showing severe CCL21
![Page 22: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/22.jpg)
PCI for LADPCI for LAD- - Rotablator 22
![Page 23: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/23.jpg)
Stent deployment23
![Page 24: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/24.jpg)
Rotational Atherectomy and IVUS
a
b
Pre
Post RA1.75 mm
burr
Post 1.75 mm burr RA
Pre
![Page 25: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/25.jpg)
DES for calcified lesion
DES use was associated with a significantly lower risk in repeat revascularization (HR = 0.57; 95% CI 0.40–0.82; P = 0.002) compared to BMS group in CCL
TAXUS-IV sub study : 9-month angiographic follow-up, DES significantly reduced the amount of late loss compared with the BMS (0.26 +/- 0.56 vs 0.51 +/- 0.48 mm, p = 0.015) in the calcific lesions
25
Sripal Bangalore, CCI 77:22–28 (2011)Moussa I, Am J Cardiol. 2005 Nov 1;96(9):1242-7
![Page 26: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/26.jpg)
Post dilation for calified lesion
Post dialation last straw for calified lesion Non compliant, high pressure balloon first
choiceBe careful coronary perforation or serious
dissection
26
![Page 27: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/27.jpg)
Postdilation in severe CCL27
![Page 28: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/28.jpg)
Clinical presentationClinical presentation
33
Diagnosis: UAP Diagnosis: UAP
Prior MIPrior MI
HypertensionHypertension
11Progressive deterioration of chest pain for 3 Progressive deterioration of chest pain for 3
years (CCS II), presented with unstable years (CCS II), presented with unstable
episodes in last 2 weeks (CCS III)episodes in last 2 weeks (CCS III)
22With a history of HBP, prior inferior and With a history of HBP, prior inferior and
anterior myocardial infarctionanterior myocardial infarction
Male, 84-year-oldMale, 84-year-old
![Page 29: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/29.jpg)
TnI levels of 0.01 ng/mL (normal
range,
<0.05 ng/mL), Cre 76umol/L, ALT
23U/L,
AST 34U/L
A 2-dimensional echocardiogram
demonstrated decreased left
ventricular
function, with an ejection fraction of
41%
Laboratory tests
![Page 30: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/30.jpg)
Electrocardiogram
![Page 31: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/31.jpg)
Coronary Angiography
![Page 32: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/32.jpg)
Coronary Angiography
![Page 33: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/33.jpg)
The patient refused the surgical solution and medical conservative therapy
After discussion the decision was made to perform sequential PCI: RCA CTO first, then unprotected LM lesions
Treatment strategy
![Page 34: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/34.jpg)
PCI for RCA
GC: JR 4.0, GW: Pilot 50Predilation BC: Sprinter 1.5 x 15mm and 2.0 x20mm
![Page 35: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/35.jpg)
Final result-RCA
DES implantation: Firebird2 2.75x33mm for d-RCA and Partner 3.0x36mm for p-RCA
![Page 36: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/36.jpg)
PCI for LMPCI for LM1 week later
GC: EBU 3.5, GW: BMW (to LAD) and Runthrough NS (to LCX)
![Page 37: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/37.jpg)
Pre-PCI IVUSPre-PCI IVUS
![Page 38: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/38.jpg)
PCI for LMPCI for LM-Predilation-Predilation
Predilation BC: Sprinter 2.5 x 15mm, 12-20atm
![Page 39: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/39.jpg)
PCI for LMPCI for LM--11stst Stent Implantation Stent Implantation
DES implantation : Firebird2 2.75x23mm for m-LAD (12atm)
![Page 40: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/40.jpg)
PCI for LMPCI for LM-2-2ndnd Stent Stent MigrationMigration
LM/p-LAD Stent Migration (Cypher 3.5x33mm), exchange to 8F sheath
![Page 41: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/41.jpg)
PCI for LMPCI for LM-Retrieving Stent-Retrieving Stent
Migrated stent was retrieved successfully assisted with Sprinter 1.5x15mm
![Page 42: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/42.jpg)
Migrated stent
![Page 43: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/43.jpg)
PCI for LMPCI for LM -Continue with Mini-Crush -Continue with Mini-Crush
Continue with 7F EBU 3.5; Mini-Crush technique was usedFirebird2 3.5x33mm for LM/p-LAD and Firebird2 3.0x18mm for LCX
![Page 44: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/44.jpg)
PCI for LMPCI for LM-Postdilation-Postdilation
Postdilatation with Avita HP 3.5x15mm (14-20atm for LM/p-LAD stent)
![Page 45: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/45.jpg)
PCI for LMPCI for LM--1st Final Final KissingKissing
1st final kissing with Avita HP 3.5x15mm (LAD) and Sprinter 3.0x12mm (LCX)
![Page 46: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/46.jpg)
2nd IVUS test LAD ostia stent expansion unacceptable
![Page 47: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/47.jpg)
PCI for LMPCI for LM--Re-postdilatation
Re-postdilatation with Avita HP 3.5x15mm (18-24atm for LM/p-LAD stent)
![Page 48: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/48.jpg)
PCI for LMPCI for LM--2st Final KissingFinal Kissing
2nd final kissingAvita HP3.5x15mm (LAD) and Sprinter3.0x12mm (LCX)
![Page 49: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/49.jpg)
Final result
![Page 50: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/50.jpg)
Final IVUS test-acceptable
![Page 51: Calcified Coronary Lesion: Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing,](https://reader035.fdocuments.in/reader035/viewer/2022062423/5697bfdf1a28abf838cb2739/html5/thumbnails/51.jpg)