Case 24: PCI Manual: LAD calcified bifurcation lesion

A patient presented with unstable angina and was found to have single vessel disease with a severe mid LAD lesion at the bifurcation of a large diagonal branch. He also had "buckshot" pellets in his chest, partially obscuring visualization of the heart and the coronary arteries! OCT showed non-circumferential calcification. Workhorse wires were placed in both the LAD and the diagonal, followed by LAD stenting and jailing of the diagonal wire. The diagonal ostium was pinched, but after rewiring the diagonal and performing balloon dilation the stenosis significantly improved. OCT post stenting showed stent malapposition that was treated with postdilation with a larger balloon. Post stenting Pd/Pa=0.87, contrast FFR=0.77, and adenosine FFR=0.74 suggesting residual disease that was localized in the proximal LAD by pressure wire pullback. After stenting the proximal LAD the FFR increased to 0.91. The patient had an uneventful recovery.