case_images: PMC10762894_01
case_images: Coronary angiography and IVUS assessment: (A) Coronary angiography showing a critical calcified stenosis in the mid left anterior descending coronary artery; (B) the stenosis improved after non-compliant balloon and lithotripsy treatment; and (C) IVUS showing the lesion length was 50 mm from normal proximal (Frame D) to the distal reference (Frame H) with corresponding markers on coronary angiography (B). IVUS also shows fractures of calcified plaque (red arrows, Frames F and G) and distal reference dimensions (Frame H). Based on IVUS, two stents were required, a 3.0 x 32 mm stent to cover from Frame D (proximal reference) to pass Frame 4G (stenosis) and a 3.0 x 20 mm stent to overlap 2 mm with the proximal stent, as a metallic roadmap, and to extend to Frame H (distal reference).
case_images: ytad561f1.jpg
case_images: PMC10762894_01_ytad561f1.jpg
case_images: ytad561-F1
case_images: Coronary angiography showed a critical calcified stenosis of the LAD artery (Figure 1A and Supplementary material online, Video S1). He was continuously hydrated and ULPCI was performed on Day 3 of admission (Summary figure and Table 1). In order to minimize the contrast use, the still diagnostic image of the LAD in the right anterior oblique view was displayed on the monitor (Figure 1A). Ultra-low contrast PCI was performed using non-compliant (NC) and lithotripsy balloons with an improvement in stenosis (Figure 1B). IVUS of the LAD showed 360  calcific arch and plaque fractures after PCI (Figure 1C, Frames 1F and 1G, and Supplementary material online, Video S2). By IVUS, the normal proximal to distal reference length was 50 mm requiring two stents (Figure 1C).
case_images: A novel technique of reverse overlapping stenting: (A) The first stent was deployed proximal to the guidewire (arrowhead) in the diagonal branch as a metallic roadmap, and (B) the second stent was deployed overlapping 2 mm distal to the first deployed stent as a metallic roadmap.
case_images: ytad561f2.jpg
case_images: PMC10762894_01_ytad561f2.jpg
case_images: ytad561-F2
case_images: The technique of reverse stenting technique included deploying the first stent proximally in which the proximal marker of the first stent (3.0 x 32 mm) was positioned just proximal to the guidewire in the diagonal branch (DB), as a metallic roadmap (arrowhead), and deployed (Figure 2A and Supplementary material online, Video S3). The second stent (3.0 x 20 mm) was overlapped 2 mm at the distal edge of the proximal deployed stent, as a metallic roadmap, and deployed with no contrast injection (Figure 2B and Supplementary material online, Video S4).
case_images: Final results: IVUS showing stents are optimally expanded (minimum stent area at the lesion site (Frame E = 6.51 mm2) with complete lesion coverage (Frames B to F with corresponding final angiogram).
case_images: ytad561f3.jpg
case_images: PMC10762894_01_ytad561f3.jpg
case_images: ytad561-F3
case_images: IVUS showed optimal stent expansion with complete lesion coverage (Figure 3 and Supplementary material online, Videos S5 and S6).