Near‐Infrared Spectroscopy‐Guided Directional Coronary Atherectomy for Left Main Bifurcation: Effective Modification of Lipid‐Rich Plaque

Directional coronary atherectomy (DCA) is an attractive option for treating bifurcation lesions, particularly when a stentless strategy is considered; however, the clinical significance of the qualitative characteristics of post-DCA residual plaque remains unclear. We report a case of a 72-year-old male undergoing percutaneous coronary intervention for a left main coronary artery (LMCA) true bifurcation lesion, in whom near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) revealed a high lipid burden. To avoid side-branch compromise, NIRS-IVUS-guided DCA was performed from the LMCA to the left anterior descending artery, observing the progressive reduction of lipid-rich plaque in real time. Adequate lumen enlargement and qualitative plaque improvement enabled a stentless strategy using drug-eluting balloons. At 7-month follow-up, angiography showed no restenosis, and NIRS-IVUS demonstrated preserved lumen dimensions and further reduction of lipid burden. This case highlights the utility of NIRS-IVUS-guided DCA in optimizing treatment decisions for bifurcation lesions by enabling real-time assessment of plaque composition and residual vulnerability, in addition to conventional indicators, including plaque burden and % plaque area.