IVUS-Optimized Sequential Rotational Atherectomy with IABP Support for Severely Calcified Unprotected Left Main Disease: A Systematic Integration Strategy—a case report

Abstract Background Severely calcified unprotected left main coronary artery disease with Grade IV calcification (360-degree circumferential arc) and prohibitive surgical risk represents an extreme-risk scenario lacking standardized management approaches. Case summary A 72-year-old diabetic male (EuroSCORE II 8.2%) with progressive angina underwent systematic six-stage percutaneous coronary intervention integrating: (1) bilateral iliac stenting for access preparation; (2) prophylactic intra-aortic balloon pump; (3) pre-procedural IVUS-characterized sequential rotational atherectomy (1.25→1.5 mm burrs) with angiography-guided burr upgrade and post-atherectomy IVUS confirmation; (4) systematic lesion preparation; (5) drug-eluting stent implantation; and (6) aggressive post-dilation achieving IVUS-optimized minimal stent area 9.39 mm2 (244% increase from baseline 2.73 mm2; maximal stent area 14.16 mm2, 419% increase). Ten-month follow-up demonstrated remarkable functional recovery with left ventricular ejection fraction improvement from 47% to 66% (40% relative increase), confirming hibernating myocardium revascularization with sustained symptom freedom. Discussion This case demonstrates that systematic integration of underrecognized access vessel preparation, mechanical circulatory support, strategic IVUS utilization at critical decision points, and evidence-driven optimization achieves excellent acute and long-term outcomes in Grade IV calcified unprotected left main disease. The reproducible six-stage framework expands treatment options for previously inoperable high-risk patients, with objective functional recovery validating aggressive intervention when surgical revascularization is contraindicated.