Fixing a Calcified LIMA: Rota, Shockwave, and DCB in a Tortuous Distal LAD with Dr. Arvin Narula and Dr. Joe Walsh

LIMA interventions are rare, high-risk, and technically unforgiving. In this MurmurMD case session, Dr. Arvin Narula and Dr. Joe Walsh walk through an extremely challenging LIMA-to-LAD lesion involving heavy calcification, tortuosity, failed prior PCI, device entrapment, rotational atherectomy, Shockwave IVL, and management of unexpected graft thrombus.This discussion delivers real-world strategy, troubleshooting, and device thinking you won’t find in textbooks.Key insights from the case:• Why left distal transradial can provide safer LIMA engagement• The moment a Corsair microcatheter is “chewed up” — and why that signals severe calcium• How to decide between more support, downsizing, or plaque modification• When rotational atherectomy is safe in a LIMA graft — and when it’s not• Why starting the burr in the native LAD, not the graft, may reduce risk• How dual preparation (Rota + Shockwave) improves expansion• DCB strategy for distal LAD disease• Managing LIMA thrombus: ACT troubleshooting, lytics, aspiration, and stent “tattooing”• Tricks for keeping thrombus from embolizing distally• How to avoid dissecting the LIMA ostium during exchanges• What to do if ACT remains subtherapeutic despite multiple bolusesThis is an advanced case with invaluable pearls for anyone treating heavily calcified coronaries, bypass graft disease, or LIMA interventions.🔔 Subscribe for more insights from interventional experts and real-world program builders.📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvAChapters:00:00 – Why LIMA interventions are challenging 00:40 – Patient background and LIMA access strategy 01:20 – Tortuosity, calcium, and microcatheter difficulty 02:00 – Deciding to escalate to rotational atherectomy 02:40 – Rota technique and safety considerations in LIMA 03:30 – Adding Shockwave for dual preparation 04:10 – DCB strategy for distal LAD disease 04:50 – Managing sudden LIMA thrombus and low ACT 05:40 – Final result and key takeaways#ComplexPCI #LIMAIntervention #RotationalAtherectomy #ShockwaveIVL #DCB #Atherectomy #CoronaryCalcium #InterventionalCardiology #BypassGraftPCI #CathLab #MurmurMD