1. Patient Demographics: AGE: 67 year old Gender: Female Cardiac risk Factors: Hypertension, Diabetes, hypercholesterolemia Clinical Presentation: NSTEMI Cardiac Catheterization Findings: LM: Calcified distal 80%-90% stenosis. LAD: Ostial 90%, Calcified vessel.mid 80% stenosis. LCX: Dominant. OM2 Proximal 70% stenosis. RCA:Small vessel. Distal 80% stenosis. LV function: Normal wall motion, EF: ~50% R. Castillo, SUNY Downstate Medical Center Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). SCAI C3 Summit Chicago May 12-13, 2006

2. Treatment recommendation: CABG -> Patient refused. Patient stabilized and discharged home for elective PCI. PCI strategy: Direct stenting of mid LAD and distal LM-Ostial LAD with DES at high pressure. Provisional PCI of proximal LCX if needed. Tirofiban Bolus to achieve PAU 200 sec. Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). SCAI C3 Summit Chicago May 12-13, 2006 R. Castillo, SUNY Downstate Medical Center

3. SCAI C3 Summit Chicago May 12-13, 2006 Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). R. Castillo, SUNY Downstate Medical Center Baseline AP Cranial and AP Caudal: LM and mid LAD calcified stenosis

4. SCAI C3 Summit Chicago May 12-13, 2006 Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). R. Castillo, SUNY Downstate Medical Center AP Cranial Cypher 3.0x8, 26atms

5. SCAI C3 Summit Chicago May 12-13, 2006 Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). R. Castillo, SUNY Downstate Medical Center AP Caudal Cypher 3.5x18, 26atms

6. SCAI C3 Summit Chicago May 12-13, 2006 Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). R. Castillo, SUNY Downstate Medical Center Quantum maverick 4.0x12, 18 atms x 2 AP caudal

7. SCAI C3 Summit Chicago May 12-13, 2006 Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). R. Castillo, SUNY Downstate Medical Center Final Result AP caudal RAO Cranial

8. Brief Case Summary: 67 year old female with calcified severe LM and LAD stenosis treated with direct, very high pressure deployment, Cypher DEStents. Allowing for very good dilatation and apposition of the stent into the vessel wall. Take Home Points High pressure deployment of stent assure good apposition and expansion of the stent. Short and simple approach to lesion reduce complications. LM stenting is safe and feasible procedure. Good anticoagulation and antithrombotic tto is crucial. R. Castillo, SUNY Downstate Medical Center Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms). SCAI C3 Summit Chicago May 12-13, 2006

9. REFERENCES: Matthew J. Price, Ecaterina Cristea, Neil Sawhney, John A. Kao, Jeffrey W. Moses, Martin B. Leon, Ricardo A. Costa, Alexadra J. Lansky and Paul S. Teirstein. Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization. J Am Coll Cardiol. 2006 Feb 21;47(4):871-7 Alaide Chieffo, Goran Stankovic, Erminio Bonizzoni, Eleftheria Tsagalou, Ioannis Iakovou, Matteo Montorfano, Flavio Airoldi, Iassen Michev, Massimo Giuseppe Sangiorgi, Mauro Carlino, Giancarlo Vitrella and Antonio Colombo. Early and Mid- Term Results of Drug-Eluting Stent Implantation in Unprotected Left Main. Circulation. 2005 Feb 15;111(6):791-5 Poludasu S. and Jonathan D. Marmur et al. “A single Center Study of Bolus only glycoprotein IIb/IIIa Inhibitors (Tirofiban) during PCI”. SUNY-Downstate. Annual Research day, April 20 2005. Case Title: Unprotected Left main intervention using a DES at very high pressure (26 Atms).