Title
CT-Guided PCI for Complex Calcified Left Anterior Descending (LAD) Artery Disease
Introduction
CCTA is increasingly used for the noninvasive evaluation of coronary artery disease. Beyond diagnosis, CCTA allow for pre-procedural planning before invasive coronary angiography. CT-guided PCI may be particularly useful in complex calcified coronary lesions where optimal device selection, calcium modification strategy, and landing zones are critical for procedural success. We present a case demonstrating the utility of CT-guided PCI planning in complex calcified LAD disease.
Clinical Case
A 79-year-old man with hypertension, hyperlipidemia, prior RCA PCI, and a remote smoking history presented with progressive exertional chest discomfort for 3-4 weeks. A CCTA was ordered that showed a right-dominant system with calcified atherosclerosis involving the left main (LM) and LAD. A ≥70% proximal LAD stenosis with partially calcified plaque and additional mid-LAD disease was identified. CT plaque analysis revealed a long (54 mm) calcified lesion extending from the LM into the LAD with circumferential calcium near the diagonal branch. Pre-procedural CT planning informed guide catheter selection, stent sizing, and the need for upfront calcium modification with intravascular lithotripsy (IVL).
During invasive coronary angiography, the circumflex artery was physiologically assessed with a pressure wire and demonstrated a dPR of 0.98, indicating no hemodynamically significant disease. The LAD and diagonal branch were wired using a dual-lumen microcatheter. Intravascular ultrasound (IVUS) confirmed severe calcified LAD disease extending from the proximal to mid-LAD with an eccentric calcific nodule.
Calcium modification was performed using IVL with 2.5 × 12 mm and 3.5 × 12 mm balloons followed by additional lesion preparation with noncompliant and scoring balloons. Stenting was performed with a 2.5 × 30 mm drug-eluting stent to the mid-LAD overlapped proximally with a 3.5 × 24 mm stent extending from the proximal LAD into the left main. Final post-dilation was performed with a 4.0 mm noncompliant balloon.
Final angiography demonstrated an excellent result. Post-PCI physiology showed an LAD FFR of 0.93 and circumflex FFR of 0.91. IVUS confirmed good stent expansion and apposition without edge dissection.
Discussion
This case highlights the growing role of CT-guided PCI in the management of complex CAD. Pre-procedural CCTA enabled comprehensive assessment of lesion morphology, plaque composition, bifurcation anatomy, and vessel dimensions and stent sizing, which facilitated procedural planning. Early recognition of extensive calcification allowed for upfront intravascular lithotripsy, which facilitated effective lesion preparation and stent expansion. Additionally, integration of physiologic assessment and intravascular imaging ensured appropriate revascularization with optimal procedural outcomes.
CT-guided PCI represents a promising strategy to improve procedural planning and efficiency by optimizing appropriate upfront device and strategy selection, minimize contrast use and fluoroscopy time, and enhance outcomes in patients with complex calcified coronary lesions.