1. Server Stenosis of LCX Orifice and bad stenting final result : Short Period follow-up(6Ms) People’s Hospital of Zhengzhou Universty, PR China ( 河南省人民医院 ) Dr. Chuanyu Gao ( 高传玉 )

2. Case History Male 78 ys High Degree AVB with AF and Single Chamber Pacer-Maker implantation Unstable Angina Pectoris Orifice of LCX : 90% with calcification

3. Ralated changes AF+III ° AVB +LBBB LVEDd 56 mm, EF 50% BNP 188pg/L Ch 2.21mmol/L, TG 0.47mmmol/L BS 3.08 D-Dimer 0.91(<0.5)ul/mL °

4. RCA basically was normal, LCX orifice was significant stenosis around 90% with very significant calcification and strange plaque surface. Distal Left Main Was Involved about 50% stenosis.

5. PCI Treating Design Femoral Approach 7F Guiding Two wires (LAD and LCX) Rotablator / cutting balloon if needed Cullotte Stenting or Provinsional T stent (lcx) IVUS assistant

6. Femoral approach, 7F JL4 Guiding BMW wiresX 2, Swapped to Pilot 50 wire in LCX spended long time for wiring

7. Difficult to wire LCX

8. Mini-Trek 2.0x15 Balloon 10atmx10sx2 times

10. Flextome Cutting balloon 2.75X6mmX3 times, 10atmx10s

11. Images: After Cutting Balloon AND Before Stenting

12. Mid LcxLeft Main

13. Abbott Xience V 3.5X23 Stent Position stent from Beginning of LM to LCX

14. Abbott Xience V 3.5X23 Stent 18 atmx20 s Contrast : before stenting Stenting …..

15. Some dissected at the bending and the bottom of Crux ( contrast stained)

16. Dissection and Residual narrow at Circumflex : Hazy on the top and contrast stain under circumflex LAD orifice involved and some narrow

18. Sprinter 2.0x12, 3.5x12 dilated LAD

19. Sprinter 3.5x12, 3.5x12 dilated LAD with kissing skill

20. After stenting:

21. Voyager NC 4.0x12 –post dilatation to LCX and LM LCX orifice hazing Dissection worsened? Stent strut broken? New thromsosis?

23. Connecting position Images of Circumflex : stent deformed and heamorage under itima?

25. Question and what we do for the situation Implant another stent in circumflex Implant second stent in LAD T—stent in LAD Cullotte stent Stop the procedure and strengthen anticoagulation Follow-up 6months with non-symptom

26. Follow-up 6months with non-symptom Lcx-LM

27. Follow-up 6months with non-symptom: angiogram findings

31. Follow-up 6months with non-symptom: IVUS findings

32. Conclusion Calcification lesion is very hard sometimes Calcification lesion is very difficult to evaluate, judge and manage The PCI is very difficult to decide which further skill is fit for him Calcification lesion is relatively statble. Please give some suggestion and discussion: best way for treatment ?

33. THANK YOU FOR YOUR GUIDING ANG SUGGESSTION And for your attention!