Case 46: PCI Manual - Calcification + tortuosity in prior CABG patient

A patient with prior CABG presented with NSTEMI. The culprit lesion was located proximal to the SVG-OM2 anastomosis which together with a severe near total proximal circumflex stenosis limited flow to the second obtuse marginal branch and the distal circumfex. Retrograde attempts for crossing the circumflex failed. Antegrade crossing was successful with a polymer jacketed guidewire (Fielder FC). Predilation with a Threader resulted in balloon rupture. After multiple rounds of orbital atherectomy the lesion successfully expanded with an excellent final result after stenting. This case illustrates the complexities of coronary artery disease in prior CABG patients, especially tortuosity and calcification, that can hinder both wiring and lesion expansion often requiring advanced wiring and plaque modification techniques.