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 boluses

This is an advanced case with invaluable pearls for anyone treating heavily calcified coronaries, bypass graft disease, or LIMA interventions.

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Chapters:

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